POSTMENOPAUSAL BLEEDING

Bleeding per vagina following established menopause is called postmenopausal bleeding. The significance of postmenopausal bleeding, whatever slight it may be, should not be underestimated. As many as one-third of the cases are due to malignancy. The same importance is also given to those cases where normal menstruation continues even beyond the age of 55 years.

Causes

The causes of postmenopausal bleeding are :

• ·         Senile endometritis
• ·         Atrophic endometrium.
• ·         Endometrial hyperplasia
• ·         Dysfunctional uterine bleeding.
• ·         Genital malignancy.

n  Carcinoma of the cervix, endometrium, vagina, vulva and Fallopian tube.

n  Sarcoma uterus.

n  Granulosa cell tumor of the ovary.

• ·         Uterine polyp.
• ·         Tubercular endometritis.
• ·         Cervical erosion and polyp.
• ·         Senile vaginitis.
• ·         Decubitus ulcer.
• ·         Retained and forgotten foreign body such as pessary or IUCD.
• ·         Withdrawal bleeding following estrogen intake.
• ·         Urethral caruncle, polyp, prolapse mucosa orcarcinoma.

Unknown is about 25 percent. The incidencehowever decreases with wider use of hysteroscopy.

Initial step is to establish the fact that it is vaginal bleeding and not bleeding per rectum or hematuria.

Detail history should be taken regarding,

• ·         Age of menopause.
• ·         Menstrual pattern prior to menopause.
• ·         Amount of bleeding, number of episodes.
• ·         Sensation of something coming out of the introitus.
• ·         Urinary problems like dysuria or frequency ofurination.
• ·         Intake of estrogen—Even if the history of intakeis present, full investigations should be carried outto exclude malignancy.
• ·         Family history of endometrial and/or ovariancarcinoma (first degree relative).

Obesity and hypertension are often related to endometrial carcinoma. Enlarged groin or supraclavicular lymph nodes may be palpated. Metastatic nodules in the anterior vaginal wall may be present. Breasts should be palpated because gynecological symptoms may be related to breast cancer

Ultrasonography transvaginal probe (TVS) is more accurate because of its proximity to the target tissue (endometrium). Endometrial thickness less than 5 mm indicates atrophy. On the other hand, thick polypoid endometrium (9–10 mm), irregular texture, fluid within the uterus require further evaluation (to exclude malignancy).

Saline infusion sonography (SIS) is more accurate compared to sonography alone and biopsy is taken.

Hysteroscopic evaluation and directed biopsy.

Endometrial biopsy may be done using the Sharman curette as an outpatient basis.

Fractional curettage, if the cervical cytology becomes negative.

Endometrial biopsy for diagnosis of endometrial carcinoma under guidance of sonohysterography or hysteroscopy has got the similar diagnostic accuracy.

Laparoscopy in suspected cases of ovarian or adnexal mass.

CT and MRI may be useful in selected cases of postmenopausal bleeding.

Detection of a benign lesion should not prevent further detailed investigations to rule out malignancy.

If the cause is found, the treatment is directed to it.  If no cause is detected and there is only minimal bleeding once or twice, careful observation is mandatory, if conservatism is desired.In cases of recurrences or continued bleeding whatever may be the amount, it is better to proceed for laparotomy and to perform hysterectomy with bilateral salpingo-oophorectomy. Unexpectedly, one may find a pathology either in the ovary or Fallopian tube or else, an uterine polyp — benign or malignant may be evident in the removed uterus