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- 1. POSTMENOPAUSAL BLEEDING POSTMENOPAUSAL BLEEDING DR;MANAL BEHERY Professor OB &GYNE 2014
- 2. Def Def Postmenopausal bleeding is any Postmenopausal bleeding is any vaginal bleeding that occurs after vaginal bleeding that occurs after 12 months of amenorrhoea in a 12 months of amenorrhoea in a postmenopausal women . postmenopausal women . The age of menopause is variable, The age of menopause is variable, but for most women it is 51 year but for most women it is 51 year
- 3. Causes of postmenopausal uterine Causes of postmenopausal uterine bleeding bleeding Atrophic vaginitis Atrophic vaginitis 60-80% 60-80% Estrogen treatments Estrogen treatments 15-25% 15-25% Polyp cervical –uterine Polyp cervical –uterine 2-12% 2-12% Endometrial Hyperplasia Endometrial Hyperplasia 5-10% 5-10% Enodometrial cancer Enodometrial cancer 10% 10% No cause found No cause found 10% 10%
- 4. Atrophic Vaginitis Atrophic Vaginitis It is the most common cause of It is the most common cause of postmenopausal uterine bleeding postmenopausal uterine bleeding 4-5 years after the menopause, 25- 4-5 years after the menopause, 25- 50% of women experience 50% of women experience symptoms due to atophic vaginitis. symptoms due to atophic vaginitis.
- 5. Cervical polyp Cervical polyp It is the second most It is the second most common cause of common cause of postmenopausal postmenopausal bleeding bleeding
- 6. Hormone replacement therapy(HRT Hormone replacement therapy(HRT ( ( Any vaginal bleeding in a Any vaginal bleeding in a menopausal woman other than the menopausal woman other than the expected cyclical bleeding that expected cyclical bleeding that occurs in women taking sequential occurs in women taking sequential HRT should be managed HRT should be managed
- 7. Endometrial hyperplasia &Endometrial Endometrial hyperplasia &Endometrial cancer cancer reassure women that only 10 percent of those presenting with postmenopausal bleeding will have endometrial cancer 90 per cent of women with endometrial cancer will present with vaginal bleeding
- 8. idiopathic cause idiopathic cause 10–15 %of patients, no evident cause for the 10–15 %of patients, no evident cause for the bleeding will be found. bleeding will be found. It is therefore necessary to look for blood in the stool It is therefore necessary to look for blood in the stool or urine, especially if the source of bleeding is or urine, especially if the source of bleeding is unclear. unclear.
- 9. Investigations Investigations History History Clinical examination Clinical examination Cervical cytology (if appropriate( Cervical cytology (if appropriate( Ultrasound scan Ultrasound scan Saline infusion sonography Saline infusion sonography Outpatient hysteroscopy Outpatient hysteroscopy Endometrial biopsy Endometrial biopsy
- 10. History History
- 11. 1 1 - - Duration and severity Duration and severity No evidence of association with pattern of bleeding and malignancy eg: one off bleed vs regular bleeding
- 14. Past medical and surgical history Past medical and surgical history • FHistory of colorectal, endometrial or other cancers associated with hereditary non-polyposis colorectal cancer Lynch ll syndrome
- 15. Clinical examination Clinical examination •General: •obesity? •thyroid? pallor? •pulse? Cachexia?
- 16. Abdominal and pelvic Abdominal and pelvic examination examination
- 17. Speculum examination of the cervix Speculum examination of the cervix
- 22. Transvaginal ultrasound (TVUS Transvaginal ultrasound (TVUS ( ( • Thickened (>5mm( endometrial stripe in postmenopause ALWAYS needs further evaluation .
- 23. Normal TVUS with endometrial Normal TVUS with endometrial thickness <4mm, thickness <4mm, with normal examination does not with normal examination does not require further investigation require further investigation providing bleeding has STOPPED. providing bleeding has STOPPED.
- 24. Saline infusion sonography Saline infusion sonography
- 25. Sonohysterography Sonohysterography TVS may miss small polyps TVS may miss small polyps Difficult to distinguish from thickened Difficult to distinguish from thickened endometrium endometrium SHG helps in SHG helps in accurate diagnosis accurate diagnosis
- 28. Endometrial Endometrial biopsy biopsy a tissue sample is taken from the lining of the uterus a tissue sample is taken from the lining of the uterus (endometrium(, (endometrium(, and is checked under a microscope for any abnormal and is checked under a microscope for any abnormal cells or signs of cancer. cells or signs of cancer.
- 29. Endometrial sampling Endometrial sampling All women with persistent menorrhogia All women with persistent menorrhogia To diagnose or exclude To diagnose or exclude endometrial carcinoma or endometrial carcinoma or Hyperplasia Hyperplasia
- 30. Endometrial Suction Curette Endometrial Suction Curette Pippelle : most commonly used, least discomfort Karman Cannula Endometrial Brush Superior in Post-Menopausal Same as Pipelle in Pre-Menop. A( Pipelle endometrial suction curette. (B( Vabra aspirat . Tao Endometrial Brush
- 31. Sampling How Sampling How ? ? Endometrial aspiration Endometrial aspiration Conventional D&C Conventional D&C Hysteroscopy & directed biopsy Hysteroscopy & directed biopsy
- 32. hysteroscopy hysteroscopy The Gold Standard- The Gold Standard- Allows Direct Visualisation Of Uterine Cavity, Allows Direct Visualisation Of Uterine Cavity,
- 33. Indication of hystroscopy Indication of hystroscopy When sampling cannot be performed When sampling cannot be performed due to cervical stenos is due to cervical stenos is Or when bleeding persists after negative Or when bleeding persists after negative biopsy. biopsy.
- 34. Endometrial hyperplasis&endometrial polyp Endometrial hyperplasis&endometrial polyp
- 36. Management of postmenopausal Management of postmenopausal bleeding bleeding
- 37. General treatment General treatment : : In some cases the blood loss may be In some cases the blood loss may be excessive, rapid and possibly life threatening excessive, rapid and possibly life threatening Correct Correct general condition general condition(Anti-shock (Anti-shock measure( measure( -Hospitalization -Hospitalization
- 38. Rapid restoration of blood Rapid restoration of blood volume,vital parameters volume,vital parameters followed by local examination to find out followed by local examination to find out the site and source of bleeding the site and source of bleeding
- 39. It is according to the It is according to the cause cause : :
- 40. Atrophic vaginitis Atrophic vaginitis treated by administration of topical oestrogen treated by administration of topical oestrogen - - Vagifem Vagifem an oestrogen within a small pessary an oestrogen within a small pessary inserted into vagina inserted into vagina , ,
- 41. Endometrial Polyps Endometrial Polyps Removed by hysteroscopy Removed by hysteroscopy
- 42. When patient presents with recurrent When patient presents with recurrent attack of bleeding attack of bleeding Do Do pelvic MRI pelvic MRI to exclude early stage E to exclude early stage E cancer cancer Do Do cytoscopy cytoscopy to exclude bladder tumors to exclude bladder tumors -DO -DO sigmoidscopy sigmoidscopy to exclude large bowel to exclude large bowel tumors if the site of bleeding is unclear tumors if the site of bleeding is unclear
- 43. MRI early stage cancer MRI early stage cancer
- 44. Endometrial hyperplasia and Endometrial hyperplasia and carcinoma carcinoma In postmenopausal women it should be surgical and include In postmenopausal women it should be surgical and include Total hystrectomy and bliateral salpingo-oophorectomy Total hystrectomy and bliateral salpingo-oophorectomy - - To avoid unnecessary risk form treatment with progesteron To avoid unnecessary risk form treatment with progesteron therapy therapy
- 45. Summary Summary Vaginal atrophy: oestrogen daily for 2 weeks, Vaginal atrophy: oestrogen daily for 2 weeks, then once- twice weekly for maintenance. then once- twice weekly for maintenance. Polyps- removed as OP Polyps- removed as OP Endometrial hyperplasia- treated with IUS or Endometrial hyperplasia- treated with IUS or progest progest Endometrial hyperplasia with atypia- should Endometrial hyperplasia with atypia- should be treated as cancer. be treated as cancer.
- 46. How to approach a case of How to approach a case of abnormal Vaginal bleeding abnormal Vaginal bleeding DR;MANAL BEHERY Professor, Zagazig University 2014
- 47. Definition Definition Any uterine bleeding that is excessive in Any uterine bleeding that is excessive in amount ,duration or frequancy amount ,duration or frequancy
- 48. Characteristics of Normal Menstruation Characteristics of Normal Menstruation
- 49. Regulation of Normal Regulation of Normal Menstruation Menstruation
- 50. How do hormones work How do hormones work ? ?
- 52. Why EP withdrawal bleeding is self limited ? Why EP withdrawal bleeding is self limited ?
- 53. 3 3 reasons reasons 1 - It is a universal endometrial event Menstrual changes occurs simultaneously in all segments of endometriaum
- 54. 3 3 reasons reasons 2 - the endometrium is structurly stable , Randome breakdown of tissue is avoided
- 55. 3 3 reasons reasons Factors involved in stopping of menses Waves of vacoconstriction Vacular stasis Endometrial collapse Clotting factors
- 57. Hormone Level Estradiol Progesterone Endometrial Thickness 0 2 4 6 8 10 12 14 16 18 20 0 2 4 6 8 10 12 14 16 18 20 Weeks Breakthrough Withdrawal Anovulatory Bleeding in PCOS Lower limit of normal
- 58. Menorrhagia Menorrhagia Prolonged (> 7 days) or excessive (> 80mL) Prolonged (> 7 days) or excessive (> 80mL) uterine bleeding occurring at regular uterine bleeding occurring at regular intervals intervals Metrorrhagia Metrorrhagia Uterine bleeding occurring at irregular Uterine bleeding occurring at irregular intervals or between periods intervals or between periods Menometrorrhagia Menometrorrhagia Uterine bleeding occurring at irregular Uterine bleeding occurring at irregular intervals, with heavy (> 80mL) or prolonged intervals, with heavy (> 80mL) or prolonged (> 7 days) menstrual flow (> 7 days) menstrual flow Polymenhorrhea Polymenhorrhea Uterine bleeding occurring at regular Uterine bleeding occurring at regular intervals of < 21 days intervals of < 21 days Oligomenorrhea Oligomenorrhea Uterine bleeding occurring at intervals of 35 Uterine bleeding occurring at intervals of 35 days or longer days or longer Amenorrhea Amenorrhea Absence of uterine bleeding for 6 months or Absence of uterine bleeding for 6 months or longer in a non-menopausal woman longer in a non-menopausal woman
- 59. classification classification Organic Organic – Systemic Systemic – Reproductive tract disease Reproductive tract disease – Iatrogenic Iatrogenic Dysfunctional Dysfunctional – Ovulatory Ovulatory – Anovulatory Anovulatory
- 60. Systemic Etiologies Systemic Etiologies Coagulation defects Coagulation defects Leukemia Leukemia ITP ITP Thyroid dysfunction Thyroid dysfunction Liver disease Liver disease
- 61. Reproductive Tract Causes Reproductive Tract Causes Gestational events Gestational events Malignancies Malignancies Benign Benign – Atrophy Atrophy – Leiomyoma Leiomyoma – Polyps Polyps – Cervical lesions Cervical lesions – Foreign body Foreign body – Infections Infections
- 62. Most Common Causes of Most Common Causes of Reproductive Tract AUB Reproductive Tract AUB Pre-menarchal Pre-menarchal –Foreign body Foreign body Reproductive age Reproductive age –Gestational event Gestational event Post-menopausa Post-menopausal l –Atrophy Atrophy
- 63. Iatrogenic Causes of AUB Iatrogenic Causes of AUB Intra-uterine device Intra-uterine device Oral and injectable steroids Oral and injectable steroids Psychotropic drugs Psychotropic drugs
- 64. Dysfunctional causes Dysfunctional causes DUB is the most DUB is the most After puberty After puberty Before menopause Before menopause After labor or abortion After labor or abortion
- 65. “ “ Doctor, I’m bleeding funny Doctor, I’m bleeding funny ” ” What is your first question? What is your first question? How do you help her define How do you help her define “bleeding “bleeding funny”? funny”? How do you quantify her bleeding? How do you quantify her bleeding?
- 66. A practical approach (step1) HISTORY A practical approach (step1) HISTORY • 1 1 - - Age Age(before puberty, reproductive age ,PM (before puberty, reproductive age ,PM ( ( • 2 2 - - Pattern of bleeding Pattern of bleeding: cyclic or a cyclic : cyclic or a cyclic • 3Marital state 3Marital state: complication of pregnancy : complication of pregnancy • 4 4 Drug intake Drug intake ,hormonal ttt, HRT ,hormonal ttt, HRT • : : 5 5 previous previous treatment treatment
- 67. ) ) Step2) Physical examination Step2) Physical examination • Abdomen Abdomen: palpable mass? : palpable mass? • Pelvis Pelvis: cervical or vaginal lesion? : cervical or vaginal lesion? • Bimanual exa Bimanual exam:uterine size m:uterine size • Speculum Speculum :cervical lesion :cervical lesion • PR PR: rectum or parametrium : rectum or parametrium
- 68. ) ) Step 3) investigation Step 3) investigation TVS TVS to assess endometrial thickness to assess endometrial thickness Sonohystrography Sonohystrography endometrial aspirate endometrial aspirate Hysteroscopy Hysteroscopy CT ,MRI for endometrial invasion CT ,MRI for endometrial invasion
- 69. Consider those investigations ONLY IF Consider those investigations ONLY IF – cervical smear cervical smear if sexually active and last if sexually active and last smear more than 1 year ago smear more than 1 year ago – CBC CBC if menorrhagia if menorrhagia – Thyroid function, coagulation profile only Thyroid function, coagulation profile only when history suggestive when history suggestive
- 70. ) ) Step4) medical ttt Step4) medical ttt For women under 40 with no suspicion of For women under 40 with no suspicion of organic lesions either organic lesions either Hormonal (for irregular bleeding as well as Hormonal (for irregular bleeding as well as menorrhagia menorrhagia ( ( – combined OC combined OC – progestogen only (21 days needed progestogen only (21 days needed ( ( Non-hormonal (for menorrhagia Non-hormonal (for menorrhagia ( ( – NSAID NSAID – antifibrinolytic agent antifibrinolytic agent
- 71. Step 5 When to refer Step 5 When to refer ? ? No response to medical treatment No response to medical treatment Over the age of 40 Over the age of 40 Uterus > 10 week size or irregular Uterus > 10 week size or irregular High risk of endometrial Cancer (obesity, DM, High risk of endometrial Cancer (obesity, DM, PCOD) PCOD) Cervical pathology suspected Cervical pathology suspected
- 72. Surgery treatment of Surgery treatment of AUB AUB – Dilation and Curettage Dilation and Curettage quickest way to stop bleeding in patients quickest way to stop bleeding in patients who are hypovolemic who are hypovolemic appropriate in older women (>35)to exclude appropriate in older women (>35)to exclude malignancy but is inferior to hysteroscopy malignancy but is inferior to hysteroscopy follow with medroxyprogesterone acetate, follow with medroxyprogesterone acetate, OCP’s, or NSAID’s to prevent recurrence OCP’s, or NSAID’s to prevent recurrence
- 74. Other modalities of treatment Other modalities of treatment Levonorgesterol releasing IUCD (Mirena Levonorgesterol releasing IUCD (Mirena ( (
- 75. 2 2 . . Endometrial ablation Endometrial ablation Hysteroscopic methods Hysteroscopic methods – Endometrial laser ablation Endometrial laser ablation – Electrosurgical endometrial ablation Electrosurgical endometrial ablation – Loop endometrial ablation Loop endometrial ablation – Roller-ball endometriaal ablation usting resectoscope Roller-ball endometriaal ablation usting resectoscope Nonhysteroscopic methods Nonhysteroscopic methods – Radio-frequency-induced thermal endometrial ablation Radio-frequency-induced thermal endometrial ablation – Microwave Microwave endometrial ablation endometrial ablation – Uterine balloon therapy Uterine balloon therapy – 3.Hysterectomy 3.Hysterectomy
- 76. ENDOMETRIAL ABLATION ENDOMETRIAL ABLATION Uterine balloon therapy Uterine balloon therapy Roller-ball endometriaal Roller-ball endometriaal ablation usting ablation usting resectoscope resectoscope
- 77. Abnormal Uterine Bleeding in Abnormal Uterine Bleeding in Women of Childbearing Age Women of Childbearing Age
- 78. Abnormal postmenopausal bleeding P Abnormal postmenopausal bleeding P Bleeding Bleeding
- 79. THANK YOU