Postmenopausal bleeding (PMB) refers to bleeding from the genital tract at least one year after menopause. It can indicate underlying malignancy and should be promptly evaluated. The most common causes are atrophic vaginitis (60-80% of cases) and hormone therapy (15-25% of cases). Evaluation of a patient with PMB includes history, exam, endometrial biopsy, and further tests if needed. Common pathologies found are polyps, hyperplasia, and cancer. Treatment depends on diagnosis but may include hormone therapy, surgery, or other options.

1. Post Menopausal
Bleeding
D O N E B Y : -
MOHAMMED ABDULBAST

2. DEFINTION
 Menopause :-
Is the permanent cessation of normal menstruation.
*Women have to stop menstruating for 12 months .
Note:-
The mean age of menopause is 51 with a normal
range from 45-56 years.

3. DEFINTION
 Post menopausal bleeding (PMB ) :-
It is bleeding from genital tract occurring at least one
year following the cessation of spontaneous menstruation.
*It is a serious symptom which may indicate the presence
of malignant disease in the genital tract.
*So Every woman with PMB should be assumed to have a
carcinoma until full investigation has proved to the
contrary.

4. The cause of post menopausal bleeding PMB are :
 A- Local causes:-
1-Uterus like Endometrial carcinoma ,
Leiomyosarcoma of uterus, Endometrial hyperplasia,
Endometritis , Endometrial polyps.
2-Cervix like Cervical carcinoma , Cervicitis , Cervical
polyp , Cervical trauma
3- Vagina like Vaginal carcinoma, Senile atrophic
vaginitis, Vaginal trauma , Foreign bodies especially
pessaries , Vaginal inflammation , Vaginal polyps.

5. The cause of post menopausal bleeding PMB are :
4-Vulva like Vulvalar carcinoma ,Vulvalar dystrophies,
, Vulvalar trauma.
5-Others like Fallopian tube carcinoma, Secondary
tumors ( ovarian, breast, colorectal carcinomas ) ,
Urethral caruncle

6. The cause of post menopausal bleeding PMB are :
 B- Systemic causes :-
o I- Bleeding disorder.. Thrombocytopenia, leukaemia,Pancytopenia,
anticoagulant.
o II- Hormone replacement .
o III- Estrogen producing tumors.
o IV- Peripheral conversion of androstenedione

7. Most Common Etiology's :-
 Atrophic vaginitis ~ 60-80%
 Estrogen therapy ~15-25%
 Endometrial or cervical polyps ~2-12%
 Endometrial hyperplasia~ 5-10%
 Endometrial carcinoma ~10%
 Cervical carcinoma~5 %

8. Atrophic Vaginitis
The majority of women with PMB will be found to have
atrophic vaginitis, whereby the vaginal epithelium thins and
breaks down in response to low oestrogen levels. This is a
benign condition, which is relatively easily treated with
topical estrogens.

9. Estrogen therapy
In women on combined cyclical HRT, bleeding in the
progesterone free period is normal.
Unscheduled bleeding refers to bleeding at other times
this is abnormal and should always be investigated.

10. Endometrial polyps
 Remove under direct visualization at hysteroscopy

11. cervical polyps
 Remove via speculum examination using polyp
forceps

12. Endometrial hyperplasia
 Is an abnormal proliferation of the endometrium
(glands). It accounts for 5_10 % of PMB.
It occurs due to excessive estrogen stimulation.
*More than 3 mm in post menopausal is significant and
5mm for those on HRT.
 classification:
1-Hyperplasia without atypia :-
Rx is Progestogens: oral preparation or LNG-IUS (Mirena)
2. Hyperplasia with atypia(premalignant) :-
Rx is Total abdominal hysterectomy as significant risk of
progression to malignancy

13. Rx Of Endo.. Hyperplasia

14. Endometrial carcinoma
 Endometrial carcinoma is 2nd most common gynecological cancer.
Is mainly adenocarcinoma arising from the lining of theuterus and
is an estrogen-dependent tumor.
 Accounts for 10% of postmenopausal bleeding.
 90% of patients with endometrial cancer will present with bleeding.
 Has 4 stages:
I. Confined to uterine body
II. Involves cervix
III. Outside uterus but inside the pelvis
IV. Extended to bladder or rectum.

15. Rx Of Endometrial CA.
 Endometrial cancer is most prevalent in the postmenopausal age
group. It typically presents withPMB.
 Risk factors include nulliparity, obesity, early menarche, late
menopause and tamoxifen exposure.
 Diagnosis is by endometrial biopsy.
 Endometrial cancer treatment should begin with staging which
involves total abdominal hysterectomy with washings, bilateral
salpingo-oophorectomy and lymph node evaluation.
 The need for postoperative adjuvant radiotherapy is determined by
recurrence risk.
 Patients with disease confined to the endometrium with little or no
invasion into uterine muscle uterus often Require only surgery.
 Where the cancer has deeply invaded into the uterine muscle or
spread outside the uterus, adjuvant therapy in the form of radio- or
chemotherapy is indicated.
 The prognosis is good when the disease is detected early.

16. Rx Of Endometrial CA.

17. Approach to PMB Management :-
-History

18. History Information:-
 1-When was your last period? (i.e. confirm menopausal)
 2-When did the bleeding start? (Hx of bleeding)
 3- Were there precipitating factors such as trauma?
 4- What is the nature of the bleeding ( temporal pattern,
duration, postictal (cervical polyp or CA) , quantity) ?
 5- History of risk factors of endometrial carcinoma as:
- Diabetes. - Hypertension -High BMI –Late menopause
- Nulliparity. - Use of unopposed oestrogen.
 6- Are there any associated symptoms such as pain, fever,
or changes in bladder or bowel function?

19. History Information:-
 7- Are there any associated symptoms such as pain, fever,
or changes in bladder or bowel function?
 8- Is there a personal or family history of a bleeding
disorder?
 9- What is the patient’s medical history and is she taking
any medications especially HRT ?
 10- Is she having coital relations ?
 11- Past obstetrics history.
 12- Past surgical history
 13-When was your last smear done? Have they always
been normal? (i.e. think cervical malignancy).

20. Approach to PMB Management :-
-Clinical examination

21. General & Systemic Examination
 General and systematic examination should be
performed to look for signs of systemic illness.
 It gives an indication to patient's general health.
-obesity?
-thyroid (hypo-hyper)? - pallor? - pulse? – blood
pressure?
- Weight loss ? - Cachexia? – fever?

22. Abdominal and pelvic examination
 careful examination of the external and internal
anatomy of the female genital tract is crucial.

23. Speculum examination of the cervix

24. Aim Of Examination To Focus On:-
1) Determine the bleeding site ( bladder, rectum,
vulva, vagina, cervix, and uterus ).
2) Note any suspicious lesions (e.g. tumor, foreign
body, laceration, cervical polyp, senile atrophic
vaginitis, ulceration from a ring pessary ).
3) Asses the size, contour, and tenderness of the
uterus.
Per rectal examination: to exclude colorectal
problems

25. Cervical smear

26. Colposcopy

27. Approach to PMB Management :-
-Investigations
• General lx:-
1. Complete blood count
2. Coagulation studies
3. LFT, RFT
4. CHEST XRAY .

28. Investigations
 specific investigations:-
1- Endometrial sampling :
A- Out patient ( Office ) endometrial sampling:
Office endometrial biopsy is an effective diagnostic technique
that is simple to perform, does not require anesthesia, and is
generally well tolerated by the patient.
 There are now many devices for performing endometrial
biopsies in the outpatient setting:
- Vabra aspiration.
- Pippelle sampling:-Pippelle : most commonly used, least
discomfort
- Hysteroscopy and directed endometrial biopsy.

29. endometrial biopsy

30. A- Pipelle endometrial suction curette. Endometrial Brush
B-Vabra aspirator

31. Hysteroscopy

32. Investigations
 B- Inpatient endometrial sampling:
I-Dilatation and curettage ( D&C ):Dilatation and curettage
(D&C ) remains the gold standard. However, D&C requires
anesthesia and is associated with a number of potential
complications.
* D&C should still be considered when the endometrial
biopsy is non diagnostic and there a high suspicion of
cancer.
II- Dilatation and fractional curettage.
III- Hysteroscopy and curettage.
Hysteroscopy and directed endometrial biopsy.
**Even hysteroscopically guided endometrial biopsy is not
100% sensitive at detecting endometrial carcinoma.

33. hysteroscopy
The Gold Standard--
D&C Allows Direct
Visualization Off Uterine Cavity

34. Investigations
2-Screen Ultrasound (endometrial thickness )
 Measurement of endometrial thickness by
Transvaginal ultrasound may play a role in screening
for uterine malignancy in women with PMB.
 An endometrial thickness exceeding 4 to 5 mm on
ultrasonography is suggestive of endometrial
pathology in such women.
 Unfortunately, ultrasonography cannot be used to
replace endometrial biopsy as a means to exclude
endometrial cancer.
 saline sonohysterogram

35. Ultrasound

36. Ultrasound Diagram

37. Investigations
3-Magnetic resonance imaging ( MRI ):
 It is expensive and not practical to screen all PMB
Women. Used for evaluation of endometrial thickness
and to predict myometrial invasion in patient suspect
to have carcinoma.
*MRI early stage cancer

38. Investigations
4- CA125 :- cancer tumor marker

39. Approach to PMB Management :-
-Management of post menopausal bleeding
General measures :
• 1- Correct general condition(Anti-shock measure):
• Hospitalization
• Assessment of blood loss:
• In some cases the blood volume loss may be
Excessive , rapid and possibly life threatening.

40. General measures :
So rapid restoration of blood volume ,vital parameters
is followed by local examination to find out the site
and source of bleeding

41. Approach to PMB Management :-
 Definitive Treatment :
The condition after diagnosis treated according to the
underlying cause .

42. AT THE END
THANK TOU FOR LESSNING
ANY ONR HAVE QUESTION
?
Cause I have one ^_^

43. Quiz?
Q/ A 65-year-old patient complains of vaginal bleeding
for 3 months. Her last menstrual period was at age 52.
She has not taken any hormone replacement .She was
diagnosed with type 2 diabetes 20 years ago and was
treated with oral hypoglycemic agents. She has chronic
hypertension, for which she is treated with oral anti-
hypertensives. Her height is 160 cm and weight 90kg.
@Physical examination is normal with a normal-sized
uterus and no vulvar, vaginal, or cervical lesions.
HOW YOU APPROCH TO HER ?

45. References
1-Susan Bewley, Ying Cheong, Sarah M Creighton…ect ,
Disorders of the menstrual cycle ch5(post menopausal
bleeding) Gynecology BY The Ten Teachers . Edition 19
(2011) .by Hodder arnold .printed in India .page 45
2- Elmar Sakala .Disorder of uterus . Ch4.USMLE in
Gynecology S2ck. edition 3 (2016).by Kaplan Medical
.Printed in new York city of united state .page 183
3-Roger P. Smith, MD. Gynecology and women health .
Section 6(uterine pathology) . NETTER’S OBSTETRICS
AND GYNECOLOGY. Second edition2008. BY Elsevier .
Printed in China .Page 296.