Detailed seminar on Menopause and Post Menopausal Bleeding

1. Physiology Of Menopause
And
Post Menopausal Bleeding
Abhijith J Puttananickal
Abishek R
Abhishek S.S
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2. DE FI NI TI O N
It is the permanent cessation of menstruation.
Menopause is retrospectively defined as the time of the last
menstrual period followed by 12 months of amenorrhea.
Mean age is 51.
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3. P HY S I O LO G Y
Ovarian failure due to the depletion of ovarian follicles.
Ovary not able to respond to FSH and LH.
Leads to cessation of ovarian production of estrogen.
Androgens may continue to be produced because the
stroma is spared.(less than in a premenopausal women)
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4. Even after the menopause low levels of oestrogen may
be seen in circulation by aromatization of the androgens
produced in the ovaries and adrenals.
Years following menopause shows an increasing
incidence of the symptoms and diseases associated with
estrogen deficiency. 4

5. HO R M O NAL LE VE LS
Estrogen ↓
Progesterone ↓
FSH ↑ (Absence of negative
feed back by ovary)
Elevated FSH is the sine-qua-non
of menopause 5

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7. Post Menopausal Bleeding
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8. DE FI NI TI O N
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Bleeding per vagina following established menopause.
SIGNIFICANCE –
Whatever slight it may be, should not be underestimated.
As many as one-third of the cases are due to malignancy.
Same importance is also given to those cases where normal
menstruation continues even beyond the age of 55 years.

9. CAU S E S
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o Senile endometritis
o Atrophic endometrium.
o Endometrial hyperplasia
o Dysfunctional uterine bleeding
o Genital malignancy
o Carcinoma of the cervix, endometrium, vagina, vulva and
Fallopian tube.
o Sarcoma uterus.
o Granulosa cell tumor of the ovary.

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o Uterine polyp.
o Tubercular endometritis.
o Cervical erosion and polyp.
o Senile vaginitis.
o Decubitus ulcer.
o Retained and forgotten foreign body such as pessary or IUCD.
o Withdrawal bleeding following estrogen intake.
o Urethral caruncle, polyp, prolapse mucosa or carcinoma.
o Unknown is about 25 percent. The incidence however
decreases with wider use of hysteroscopy.

11. M ANAG E M E NT
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Initial step is to establish the fact that it is vaginal
bleeding and not bleeding per rectum or hematuria.
Detailed history regarding
Age of menopause
Menstrual pattern prior to menopause
Amount of bleeding, number of episodes

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Sensation of something coming out of the introitus
 Urinary problems like dysuria or frequency of urination
Intake of estrogen—Even if the history of intake is present, full
investigations should be carried out to exclude malignancy.
Family history of endometrial and/or ovarian carcinoma (first
degree relative)

13. General Examination
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Obesity and hypertension are often related to endometrial
carcinoma
Enlarged groin or supraclavicular lymph nodes may be
palpated. Metastatic nodules in the anterior vaginal wall
may be present.
Breasts should be palpated because gynecological
symptoms may be related to breast cancer

14. Per Abdomen Examination
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A lump in the lower abdomen may be due to pyometra or uterine
sarcoma or adnexal mass.
Inspection of the perineum
If the uterus is outside the introitus, a decubitus ulcer may be
detected.
Careful inspection of vulva may reveal a growth If it is present, biopsy
is to be taken

15. Palpation
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To separate the labia for better inspection of the urethral meatus to
find out any caruncle, polyp or mucosal prolapse
Speculum examination: To note the condition of the cervix and
the vault of the vagina.
Any visible cervical growth → biopsy is to be taken for histology.
Cervix apparently looking normal → cervical and endocervical smear
to exclude dysplasia or CIN

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 Aspiration cytology — for endometrial carcinoma. Pipelle
endometrial sampling can be done with a long and narrow plastic
cannula
Bimanual examination
Uterus may be normal, atrophic or enlarged due to pyometra or
sarcoma.
Adnexal mass (infective or ovarian) may be palpable.

17. Special investigations
 Ultrasonography transvaginal probe (TVS) - more accurate
because of its proximity to the target tissue (endometrium).
Endometrial thickness less than 5 mm indicates atrophy.
 On the other hand, thick polypoid endometrium (9–10
mm), Irregular texture, fluid within the uterus require
further evaluation (to exclude malignancy)
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o Saline infusion sonography (SIS) - more accurate compared to
sonography & biopsy is taken.
o Hysteroscopy evaluation and directed biopsy.
o Endometrial biopsy – using Sharman curette as an outpatient
basis.
o Fractional curettage - if the cervical cytology becomes
negative.
o Endometrial biopsy - diagnosis of endometrial carcinoma under
guidance of sonohysterography
o Laparoscopy in suspected cases of ovarian or adnexal mass.
o CT and MRI may be useful in selected cases of postmenopausal
bleeding.
o Detection of a benign lesion should not prevent further detailed
investigations to rule out malignancy

19. Treatment
o If the cause is found, the treatment is directed to it
o If no cause is detected and there is only minimal bleeding once or
twice, careful observation is mandatory, if conservatism is desired.
o In cases of recurrences or continued bleeding whatever may be
the amount - better to proceed for laparotomy & to perform
hysterectomy with bilateral salpingo-oophorectomy.
Unexpectedly, one may find a pathology either in the ovary or
Fallopian tube or else, an uterine polyp — benign or malignant
may be evident in the removed uterus.
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20. THANK YOU
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