Post-menopausal bleed

Question 1

What are the causes of post-menopausal bleeding?

Answer 1

1. Atrophic vaginitis (hypoestrogenism)
2. Neoplasia
   - endometrial malignancy; adenocarcinoma, sarcoma
   - fallopian tube or ovarian malignancy
   - cervical and vaginal malignancy
3. Polps (estrogen therapy, tamoxifen)
4. Postmenopausal hormone therapy
5. Endometrial hyperplasia (endogenous estrogen production from ovarian or adrenal tumors or exogenous estrogen. obesity induced endogenous estrogen)
6. Leiomyoma (fibroids) - rule out uterine sarcoma
7. Adenomyosis - sympts not present in the absence of postmenopausal hormone therapy
8. Disease in adjacent organs - diverticulitis, urethritis, bladder cancer, UTI, IBS, hemorrhoids
9. Post-radiation therapy
10. Anticoagulation therapy
11. Herbal and dietary supplements - soy & phytoestrogens
12. Infection

Question 2

History Qs in PMB?

Answer 2

When did the bleeding start?
* Were there precipitating factors such as trauma?
* Nature of bleeding? (temporal pattern, duration, postcoital, quantity)
* Associated symptoms –pain, fever, changes in bladder or bowel function
* Medical history –history of breast cancer, diabetes mellitus
* Medications –hormones, anticoagulants
* Soy-containing herbal or dietary supplements being taken?
* Family history or breast, colon, and endometrial cancer?
* Menarche and menopause ages

Question 3

Examination in post meno bleeding:

Answer 3

BMI
determine site of bleeding
look for lesions, lacerations, foreign bodies
assess size, contour and tenderness of uterus
signs of systemic illness on general abdominal exam

Question 4

Investigations in post menopausal bleeding?

Answer 4

endometrial evaluation = biopsy or TVUS
cervical cytology

Question 5

Management of postmenopausal bleeding?

Answer 5

exclude malignancy as age is significant risk factor
uterine bleeding is usually self limited if not malig
mdt for malignancy; mets, stage and grade