Post menopausal bleeding
<ul><li>Defined as bleeding that occurs after 12 months of amenorrhea  in a middle – aged women, also women who continue t...
<ul><li>*  Post menopausal bleeding is more likely to be caused by pathologic disease than is bleeding in younger women, a...
<ul><li>II –  Gynecologic causes : </li></ul><ul><li>A –  Exogenous hormones : </li></ul><ul><li>*  Most common causes of ...
<ul><li>B –  Vaginal atrophy and vaginal and vulvar lesions : </li></ul><ul><li>*  Bleeding from the lower genital tract i...
<ul><li>2 – Endometrial polyps.Occur in up to 10% of women with PMB. </li></ul><ul><li>3 – Endometrial carcinoma,may be pr...
<ul><li>Management : </li></ul><ul><li>*  The basic premise is that an underlying pathology needs exclusion in all cases o...
<ul><li>*  A cervical smear is a routine component of the investigation of PMB. </li></ul><ul><li>*  High vaginal swabs sh...
<ul><li>*  However, those patients who have persistent bleeding or have a detectable abnormality on ultrasound require end...
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Gynecology 5th year, 7th lecture/part one (Dr. Sindus)

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The lecture has been given on May 4th, 2011 by Dr. Sindus.

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Gynecology 5th year, 7th lecture/part one (Dr. Sindus)

  1. 1. Post menopausal bleeding
  2. 2. <ul><li>Defined as bleeding that occurs after 12 months of amenorrhea in a middle – aged women, also women who continue to menstruate after the age of 55 years need to be investigated. </li></ul><ul><li>* When amenorrhea occurs in a younger person for 1 Year and premature ovarian failure or menopause has been diagnosed, episodes of bleeding may be classified as post menopausal, although resumption of ovulatory cycles can occur. </li></ul><ul><li>* Follicle stimulating hormone ( FSH ) levels are particularly helpful in the differential diagnosis of menopausal versus hypothalamic amenorrhea. An FSH level greater than 30 m IU/ml is highly suggestive of menopause. </li></ul>
  3. 3. <ul><li>* Post menopausal bleeding is more likely to be caused by pathologic disease than is bleeding in younger women, and it must always be investigated. </li></ul><ul><li>Causes : </li></ul><ul><li>I – Non – gynecologic causes : </li></ul><ul><li>These are also more likely to be caused by pathologic disease in older women, and the patient may be unable to determine the site of bleeding. </li></ul><ul><li>This could be from GIT or urinary system . </li></ul>
  4. 4. <ul><li>II – Gynecologic causes : </li></ul><ul><li>A – Exogenous hormones : </li></ul><ul><li>* Most common causes of post menopausal uterine bleeding is the use of exogenous hormones. </li></ul><ul><li>* Recently long term oestrogen / progesterone HRT is recommended for prevention of osteoporosis to improve life quality. </li></ul><ul><li>* It is not uncommon to present with vaginal bleeding for as long as 6 – 12 months after initiation of any HRT. If after this time bleeding still occur, further investigation is warranted to discover its aetiology. </li></ul>
  5. 5. <ul><li>B – Vaginal atrophy and vaginal and vulvar lesions : </li></ul><ul><li>* Bleeding from the lower genital tract is almost always related to vaginal atrophy with or without trauma. </li></ul><ul><li>* Examination reveal thin tissue with ecchymosis. </li></ul><ul><li>* With vulvar dystrophy, there may be a white area and cracking of the skin of the vulva. </li></ul><ul><li>C – Tumors of the reproductive tract : </li></ul><ul><li>The differential diagnosis of organic causes of post menopausal uterine bleeding includes : </li></ul><ul><li>1 – Endometrial hyperplasia ( simple, complex and atypical ).Found in about 15% of cases of PMB. </li></ul>
  6. 6. <ul><li>2 – Endometrial polyps.Occur in up to 10% of women with PMB. </li></ul><ul><li>3 – Endometrial carcinoma,may be present in 7-10% of women with PMB . </li></ul><ul><li>4 – rare tumors such as cervical or endocervical carcinoma,peak incidence in5th and 6 th decade of life ,may present with PMB often with an offensive blood stained discharge. Uterine sarcoma, or even tubal carcinoma and ovarian carcinoma especially oestrogen secretory ovarian tumors,are other rare causes of PMB . </li></ul>
  7. 7. <ul><li>Management : </li></ul><ul><li>* The basic premise is that an underlying pathology needs exclusion in all cases of PMB. In most cases endometrial sampling will be required. </li></ul><ul><li>* An initial thorough examination looking for signs of systemic diseases is extremely important. </li></ul><ul><li>* Pelvic examination include an evaluation of the oestrogenic state of the vagina and cervix, Characteristic finding include a pale and thin appearance of the vaginal mucosa often with a loss of the normal rugea. </li></ul>
  8. 8. <ul><li>* A cervical smear is a routine component of the investigation of PMB. </li></ul><ul><li>* High vaginal swabs should be taken if discharge is present. </li></ul><ul><li>* The use of U/S as an initial step at investigation has some advantages. It is less invasive, sensitive, cheaper and allows visualization of other pelvic organs. </li></ul><ul><li>An endometrial thickness of 4 mm or more is used to identify those cases that require further investigations. Particularly useful in older patients who are less likely to tolerate more invasive investigations. </li></ul>
  9. 9. <ul><li>* However, those patients who have persistent bleeding or have a detectable abnormality on ultrasound require endometrial sampling. </li></ul><ul><li>* Outpatient aspiration techniques can be used but hysteroscopically directed biopsy should be performed if bleeding continue despite a normal aspiration sample, hystroscopy done in the office or operating room may prove helpful in locating endometrial polyp or fibroid that may be missed even by fractional curettage . </li></ul><ul><li>* Treatment will be directed at the inderlying aetiology. </li></ul>

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