Postmenopausal bleeding is abnormal genital tract bleeding that occurs at least one year after menopause. The most common causes are atrophic vaginitis, hormone replacement therapy, and endometrial polyps. Evaluation involves history, examination, ultrasound, and endometrial biopsy to determine the etiology, as some causes like endometrial cancer require treatment such as hysterectomy. Management is aimed at treating the underlying cause, with topical estrogens for atrophic vaginitis and progestogens for endometrial hyperplasia.

1. POSTMENOPAUSAL BLEEDING
MANAHIL JAMIL

2. MENOPAUSE
 Menopause: Woman’s last menstrual period
 Post menopause: all women who have been 1 year since their last period are
deemed postmenopausal
 Cause is cessation of regular ovarian function

3. EFFECTS OF MENOPAUSE BY TIME OF ONSET

4. POSTMENOPAUSAL BLEEDING
 It is bleeding from genital tract occurring at least one year following the cessation of
spontaneous menstruation.
 serious symptom - indicates the presence of malignant disease in the genital tract.
 Every woman with PMB should be assumed to have a carcinoma until full
investigation has proved to the contrary.

5. CAUSES
Local causes Systemic causes
Uterus
Endometrial carcinoma, Leiomyosarcoma of uterus, Endometrial
hyperplasia, Endometritis, Endometrial polyps
Bleeding disorder
(Thrombocytopenia,
leukemia, Pancytopenia,
anticoagulant)
Cervix
Cervical carcinoma, Cervicitis, Cervical polyp, Cervical trauma
Hormone replacement
therapy
Vagina
Vaginal carcinoma, Senile atrophic vaginitis, Vaginal trauma, Foreign
bodies especially pessaries, Vaginal inflammation, Vaginal polyps.
Estrogen producing
tumors.
Vulva
Vulvar carcinoma, Vulvar dystrophies, Vulvar trauma.
Others Fallopian tube carcinoma, Secondary tumors (ovarian, breast,

6. MOST COMMON ETIOLOGIES
 Atrophic vaginitis ~ 60-80%
 Estrogen therapy ~15-25%
 Endometrial or cervical polyps ~2-12%
 Endometrial hyperplasia~ 5-10%
 Endometrial carcinoma ~10%
 Cervical carcinoma~5 %

7. ATROPHIC VAGINITIS
 most common cause
 4-5 years after the menopause, 25-50% of women
experience symptoms due to atrophic vaginitis
 vaginal epithelium thins and breaks down in response
to low estrogen levels. This is a benign condition,
which is relatively easily treated with topical
estrogens.

8. HRT
 HRT is used as first‐line treatment for the prevention or treatment of osteoporosis in menopausal
women
 HRT is prescribed either as an estrogen‐only preparation in women who have undergone
hysterectomy or as an estrogen–progestogen combination for women with a uterus to prevent
endometrial hyperplasia and cancer.
Cyclical HRT Continuous combined HRT
• Continuous estrogen and cyclical progesterone
for 12–14 days in a 28‐day cycle
• produce regular and acceptable bleeding after
the end of the progestogen phase
• Daily use of estrogen and progesterone
• should induce amenorrhea usually within
6 months of therapy

9. HRT
 Causes
 poor compliance
 drug interactions
 higher endogenous estrogen production in
women with obesity
 changes in the size of endometrial vessels
and stromal expression of factors such as
vascular endothelial growth factors

10. ENDOMETRIAL HYPERPLASIA
 abnormal proliferation of the
endometrium (glands). It accounts
for 5_10 % of PMB
 due to excessive estrogen
stimulation.
 More than 4 mm in post
menopausal is significant
 5mm for those on HRT

11. ENDOMETRIAL CARCINOMA
 adenocarcinoma arising from the
lining of the uterus and is an
estrogen-dependent tumor.
 90 % of women with endometrial
cancer will present with vaginal
bleeding
 Risk factors include nulliparity,
obesity, early menarche, late
menopause and tamoxifen exposure

12. APPROACH TO THE PATIENT

13. HISTORY
 Last period (i.e. confirm menopausal)
 Hx of bleeding (onset, duration, pattern, amount, color, presence of clots, postcoital, Hx of
trauma)
 History of risk factors of endometrial carcinoma (Diabetes, Hypertension, High BMI, Late
menopause, Nulliparity, use of unopposed estrogen)
 associated symptoms such as pain, fever, or changes in bladder or bowel function (pyometra
or bleed from bowel & bladder)
 personal or family history of a bleeding disorder
 patient’s medical history and medications (HRT)
 Past obstetrics history & Past surgical history
 Pap smear

14. CLINICAL EXAMINATION
 General Examination
 Obesity, thyroid (hypo-hyper), Pallor
 Weight loss, Cachexia
 fever
 Abdominal examination & Pelvic examination
 Speculum examination of the cervix
 Bimanual examination
 Per Rectal exam

15. INVESTIGATIONS
 General
 Complete blood count
 Coagulation studies
 LFT, RFT
 CHEST XRAY

16. INVESTIGATIONS
 Screen Ultrasound
 Transabdominal ultrasound
 Transvaginal ultrasound
 endometrial thickness exceeding 4 mm on
TVUSS is suggestive of endometrial pathology
 Magnetic resonance imaging ( MRI )
 CA125 cancer tumor marker

17. INVESTIGATIONS
 Hysteroscopy and curettage
 Endometrial biopsy (Vabra
aspiration, Pippelle sampling)
 Dilatation and curettage

18. MANAGEMENT
 Excessive blood loss – Correct general condition (Anti-shock measure) &
Hospitalization
 Determine cause
 Treatment according to the underlying cause

19. TREATMENT ACCORDING TO THE CAUSE
 Vaginal atrophy - Estrogen daily for 2 weeks, then once or twice weekly for
maintenance.
 Polyps (endometrial and cervical) – Remove during examination
 Endometrial hyperplasia- treated with Progestogens (oral preparation or LNG-IUS)
 Endometrial hyperplasia with atypia- should be treated as cancer (total abdominal
hysterectomy, bilateral salpingo-oophorectomy and lymph node evaluation)