A Family Doctor's Tale -POSTMENOPAUSAL BLEEDING

DOC I HAVE POSTMENOPAUSAL BLEEDING

Postmenopausal bleeding is a symptom defined as heavy or prolonged occurring one year or more after menopause.

Bleeding can occur from any part of the genital tract.

Causes:
Physiological:
most common 25 per cent show no demonstrable cause
(dysfunctional uterine bleeding)

Iatrogenic:
estrogen replacement therapy

Vulva:
infection
atrophy
granulomatous lesions
carcinoma

Vagina:
atrophy
infection
carcinoma

Cervix:
polyp
carcinoma

Uterus:
polyp
carcinoma
myomas

Others:
tubal or ovarian carcinoma
pelvic inflammatory disease
endometriosis

Diagnosis:
History:
Menstrual history:
cycle length, number of bleeding days, degree of blood loss(number of pads used per day), presence of blood clots, dysmenorrhea (painful Menstruation)


Symptoms suggesting underlying pathology:
Metabolic disorders:
symptoms of hypothyroidism

Bleeding disorders:
easy bruising
anticoagulants

Pelvic inflammatory Disease:
pelvic pain especially during intercourse
vaginal discharge
dysmenorrhea

Endometriosis:
pelvic pain
dysmenorrhea

Medication:
use of post menopausal estrogen

Physical Examination:
Signs of underlying diseases:
infection of vulva and cervix
hypothyroid features
pallour(anaemia)

Abdominal examination:
palpable uterine or ovarian masses

Pelvic examination:
vulval and vaginal examination
bimanual palpation for masses
cervical smear

Investigation:
Full blood count including hemoglobin(to exclude anemia from loss of blood) and platelets(low platelets can cause bleeding)
Transvaginal ultrasound to exclude uterine fibroids and polyps -postmenstrual scans is best when the endometrium is at its thinest.
Endometrial hysteroscopy and biopsy in women
Laparoscopy if required

Treatment:
Medications:
1.Tranexamic acid- oral antifibrinolytic, given only when there is heavy bleeding

2.oral estrogen - prevent proliferation of the endometrium, reduces blood flow. Should be given for 21 days only to assess its effect on menstrual bleeding

3. Injected progesterone -also prevent proliferation of the endometrium, induce uterine atrophy and stop menstruation

4. Levonorgestrel-releasing intrauterine system(LNG-IUS)
-also prevent proliferation of the endometrium

5.Application of estrogen cream for atrophic vulvitis and vaginitis

6.treatment of underlying causes such as bleeding causes, low platelets, hypothyroidism, and cancers

7.treat any anemia caused by post menopausal bleeding

Surgery
1.Endometrial ablation
may be done only if medications has failed

Usually involve the removal of the endometrium through the cervical opening.


There are various forms of endometrial ablation:
First generation:
hysteroscopy with general anaesthesia
-Rollerball ablation
-Transcervical resection of the endometrium

Second Generation:
non-hysteroscopy, no general anaethesia, day surgery,fast recovery
-Impedance-controlled bipolar radiofrequency ablation
-balloon thermal ablation
-microwave ablation
-free fluid thermal ablation

2. Hysterectomy
used only as a last resort in treatment of Postmenopausal bleeding
if other treatment are contraindicated
there is a desire for amenorrhea
there is no desire to retain uterus

Treatment of Underlying causes:
hypothyroidism with thyroxine tablets
reduce anticoagulant treatment if possible
treat any bleeding disease with platelets or blood factor deficient infusion
treatment of endometriosis,
antibiotic treatment of pelvic inflammatory disease
treatment of uterine carcinoma
surgical removal of fibroids and polyps

Prognosis:
generally good after hysterectomy and removal of ovaries,treatment of underlying causes.

Cancer treatment prognosis depends on severity of cancer.