Transcript Post-Menopausal Bleeding

Dr. Mohammed Abdalla
Egypt, Domiat general hospital
• is the permanent cessation of
menstruation resulting from loss of
ovarian follicular activity.
• It can only be determined after 12
months' spontaneous amenorrhoea.
• Mean age is 51 years.
• is the period of time in which the ovaries
are beginning to fail, where endocrine,
biological, and clinical changes are seen.
It ends with the final menstrual period.
• Length of the transition is approximately
4 years
is the time period over which the ovaries
are failing (when symptoms begin) up
until the cessation of menstruation, and
ends 12 months after the final
menstrual period.
is the time after the menopause, that is, after the
permanent cessation of menstruation. It can only
be determined after 12 months of spontaneous
amenorrhoea.
In practice this definition is difficult to apply,
especially in women who have started hormone
replacement therapy (HRT) in the perimenopause.
It has been estimated that by the age of 54 years,
80% of women are postmenopausal [McKinlay et
al, 1992; DTB, 1996].
occurs after bilateral oophorectomy with or
without hysterectomy.
Premature menopause may also be
radiation- or chemotherapy-induced, or
occur after hysterectomy with ovarian
conservation.
• A premature menopause is one that
occurs before the age of 40 years.
• Primary premature menopause may
occur at any age and present as
amenorrhoea. Not all women have acute
symptoms. FSH levels are elevated.
Spontaneous fertility may recur.
 It is possible to discontinue the HRT or COC pill and
measure the follicle-stimulating hormone (FSH) level
after 6-8 weeks. The POP does not affect FSH levels
and so does not need to be stopped for FSH testing
[Gebbie, 1998].
 An FSH value over 30 IU/L is in the postmenopausal
range, but should be repeated 4-8 weeks later to
confirm this.
 Even if the FSH levels are in the postmenopausal
range, this may not reliably indicate infertility, and
contraception should be continued for a further 1 year
if the woman is over 50 years old, or a further 2 years
if she is under 50 years old .
Benign conditions is most
frequent causes of PMB but
endometrial cancer is the
most serious potential
underlying cause
75% of women with
endometrial cancer
are postmenopausal.
Risk factors for endometrial cancer
are conditions typically associated with chronic elevations
of endogenous estrogen levels or increased estrogen
action at the level of the endometrium. These include
 Obesity.
 history of chronic anovulation.
 diabetes mellitus.
 estrogen-secreting tumors.
 exogenous estrogen unopposed by progesterone .
 tamoxifen use.
 a family history of Lynch type II syndrome (hereditary
nonpolyposis colorectal, ovarian, or endometrial cancer).
Investigate all bleeding during menopause
unless the patient is on cyclic replacement
therapy with normally anticipated
withdrawal bleeding.
The duration or amount (staining vs gross)
of bleeding does not make any difference.
Tamoxifen use
Tamoxifen therapy is associated with a twoto threefold increased risk of endometrial
cancer in postmenopausal women. TVUS
of patients on this therapy typically shows
an increased endometrial thickness.
Risk appears to increase with higher
cumulative doses of tamoxifen and longer
duration of treatment.
Postmenopausal bleeding and
HRT
• The occurrence of uterine bleeding or
spotting after the initiation of HRT is not
unusual. More than half of HRT users will
have some spotting or bleeding at the
beginning of therapy.
• Usually such bleeding is lighter than a
menstrual period and lessens with time;
after 6 months, it stops completely in most
women.
Postmenopausal bleeding and
HRT
Sequential (or cyclical) combined regimens
cause scheduled bleeding in most users.
Continuous combined regimens are
associated with a reduced relative risk of
endometrial cancer but may cause
unpredictable spotting or bleeding during
initial use.
Systemic conditions
Abnormalities of the hematologic system also
must be considered as a possible cause of
postmenopausal bleeding.
On rare occasions, AUB will be the first sign of
leukemia or a blood dyscrasia.
Overuse of anticoagulant medications such as
aspirin, heparin, and warfarin-which are
taken with greater frequency by patients in
this age group-may contribute to
postmenopausal bleeding.
• Once menopause occurs, estrogen and
progesterone are no longer produced by the
ovaries; nor are they produced in any
appreciable amounts by the liver and fat.
The endometrium regresses to some
degree, and no further bleeding should
occur. When bleeding does resume,
therefore, endometrium must be evaluated.
Endometrial evaluation is called for when :
1. any menopausal woman not taking HRT
develops uterine bleeding after more than 1
year of amenorrhea.
2. any postmenopausal woman on HRT for 6
months or more with persistent uterine
bleeding.
3. and any previously amenorrheic woman on
HRT who begins bleeding without apparent
cause.
As TVUS is a non invasive test with 91 % sensitivity
and 96 % specificity . it should be done for all
women with postmenopausal bleeding.
if the endometrial thickness is >5mm. and if the
patient pre test probability is low ,office endometrial
biopsy and SIS should be done to determine
whether the endometrium is symmetrically
thickened.
BUT if the patient pre test probability is high , a
fractional curettage biopsy or a hysteroscopic
guided biopsy is recommended.
TVUS
endometrial
thickness is > 5mm
If low risk
office endometrial
biopsy and SIS
If high risk
D/C biopsy OR
hysteroscopy
endometrial
thickness is < 5mm
follow
But symptoms
persist
In women with continued bleeding after a negative initial evaluation, further testing
with hysteroscopically directed biopsy is essential,
Vaginal ultrasonography.
Hydrosonography.
Endometrial biopsy.
Office biopsy.
D/C biopsy.
Hysteroscopic guided biopsy.
Sensitivity and specificity are
often used to summarise the
performance of a diagnostic
test. Sensitivity is the probability
of testing positive if the disease
is truly present. Specificity is the
probability of testing negative if
the disease is truly absent.
Transvaginal ultrasound has a good correlation
with pathologic endometrial findings. Using an
endometrial thickness from myometrium to
myometrium of 5 mm (considered the upper limit
of normal) sensitivity is 91 percent and
specificity is 96 percent.
Although the test is very specific , it isn't sensitive.
Many women without endometrial cancer will
have an endometrial thickness of 5 mm or more
Identification and measurement
of the endometrial echo and
descriptions of the echogenicity
and heterogeneity of the
endometrium are key to defining
endometrial health
A cut-off threshold of 3 mm or 5mm ?
A ‘negative’ TVUS result for a local cut-off
point of 3 mm is therefore less likely to
miss cancer (i.e. have a greater sensitivity)
than cut-offs of 5 mm.
But unfortunately a lower cut-off points also
result in a greater proportion of ‘false
positives’ requiring further investigation.
A cut-off threshold of 3 mm or 5mm ?
Adopting more than one cut
off value may allow the
interpretation of the test to
be tailored to the patient’s
pre-test probability (i.e. the
patient risk group).
the patient risk group
•Low pre-test probability
•On HRT
•On tamoxifen therapy
•High pre-test
Probability (high risk)
Cut off threshold 5mm
Cut off threshold 3mm
If both pre-and post test
probability are reassuring, no
further action need be taken.
Further investigations should
be carried out if symptoms
recur.
If both pre-and post test
probabilities are not satisfactory
with this level of reassurance,
further investigation is justified.
This should include an
endometrial biopsy to obtain a
histological assessment.
For women on sequential
combined HRT presenting with
unscheduled bleeding, or
those who are tamoxifen users,
TVUS using a cut-off point of 5
mm or less should be used to
exclude endometrial cancer.
One of the difficulties with using the
endometrial stripe as a criterion for further
diagnostic tests (eg, endometrial biopsy) is
that several conditions may be present
that give a false reading on the
endometrial stripe. This is particularly true
in a patient who might have an
endometrial polyp or who has been taking
tamoxifen.
The introduction of intrauterine fluid
(saline-infusion sonography)
during transvaginal ultrasound is
one of the most significant
advances in ultrasonography of
the past decade.
Uterine fibroids and adenomyomas generally
are apparent on ultrasound. Uterine polyps
may appear as a thickened endometrial
stripe, but these and submucous myomas
can be clearly identified as filling defects
when a sonohysterography is performed
At transvaginal US, when the endometrium
cannot be accurately measured or when there
is a nonspecific thickened central endometrial
complex, sonohysterography can provide
additional information and can be used to
direct the patient to a visually guided
hysteroscopic procedure rather than a
potentially unsuccessful blind biopsy
procedure.
At transvaginal ultrasonography , the finding of
a thickened central endometrial complex,
with or without cystic changes, is often
nonspecific.
The Thickened endometrium may
be a polyp
CYST
POLYP
With polyps the endometrial-myometrial
interface is preserved
well-defined, homogeneous,
isoechoic to the endometrium
The Thickened endometrium may be a
polyp
catheter
With polyps the endometrial-myometrial
interface is preserved
POLYP
The Thickened endometrium may
be a Submucosal leiomyomas
With myomas the endometrialmyometrial interface is distorted
broad-based, hypoechoic,
The Thickened endometrium may
be an endometrial hyperplasia
Endometrium thickness = A-B
A
B
diffuse thickening of the echogenic
endometrial stripe without focal
abnormality
Endometrial cancer
Endometrial cancer is typically a diffuse process,
but early cases can appear as a polypoid mass
Dilatation and curettage
The role today of the formal D&C
probably is very limited because
the diagnosis usually can be
made in the office.
Hysteroscopic-directed
biopsy
Hysteroscopic visualization has several advantages:
immediate office evaluation,
visualization of the endometrium and endocervix,
the ability to detect minute focal endometrial
pathology and to perform directed endometrial
biopsies.