Post-menopausal bleeding
Case Presentation
• A 56 year old nulliparous women present with post-menopausal
bleeding. How would you counsel her?
Definition
• Uterine bleeding in post-menopausal women more than a year after
last menstrual bleeding.
• Approximately 10% of patients presenting with postmenopausal
bleeding will have a gynaecological malignancy.
• There will however, be occasional cases of cervical, vaginal, vulval and
ovarian cancer which are referred with post-menstrual bleeding.
Etiology
Most common causes:
• Atrophic vaginitis– 59%
• Endometrial hyperplasia – 10%
• Endometrial polyp – 9%
• Endometrial carcinoma– 5-10%
• Bleeding related to the use of HRT
Rare causes:
• Uterine fibroids
• Adenomyosis
• Cervial polyp
• Cervical cancer
Risk factors
• Nulliparity
• Overweight
• Early menarche, late menopause
• Tamoxifen exposure
• Hormone replacement therapy
• Oral oestrogen treatment
Diagnostic evaluation
• A physical examination is recommended in women with PMB within 4
weeks due to high rick of endometrial cancer
Primary Evaluation
• Includes medical history, clinical examination, transvaginal ultrasound
with evaluation of endometrial lining thickness, cervical cytology and
endometrial biopsy.
Secondary evaluation
• Vaginal ultrasound evaluation possibly combined with saline infusion
into the uterine cavity
• Repeated endometrial biopsy
• Diagnostic hysteroscopy with endometrial biopsy
• Dilatation and curettage
Endometrial carcinoma
Aetiology
• There is an association with high circulating levels of oestrogen.
• In post-menopausal women, conversion of androgens to oestrogen
occurs in adipose tissue, there is also interaction with insulin-like
growth factor.
• Tamoxifen(SERM) used to prevent recurrent breast cancer by blocking
oestrogen receptors in the breast, is known to increase the risk of
endometrial cancer. This is most likely due to a weak oestrogenic
effect on the endometrium.
Risk factors
• Obesity
• Diabetes
• Nulliparous
• Late menopause >52 years old
• Unopposed oestrogen therapy
• Tamoxifen therapy
• Hormone replacement therapy
• Family history of colorectal or ovarian cancer
Clinical features
• The most common symptom is abnormal vaginal bleeding
• In advanced cases, patients may present with evidence of fistula,
bony metastases, altered liver function or respiratory symptoms.
Diagnosis
• At examination, blood may be noted arising from the cervix on
speculum examination.
• Bimanual examination if the uterus may reveal an enlarged uterus.
• Transvaginal ultrasound scans are often performed in the outpatient
clinic and allow a quick and accurate assessment of endometrial
thickness.
• Hysteroscopy allows direct visualization of the whole endometrium
and allows a directed biopsy to be performed.
Staging
Management
1. Surgery
• Extent of surgery depend on a number of factors including grade of
disease, MRI stage and patient’s comorbidities.
• Standard surgery is a total hysterectomy, bilateral salpingectomy.
• This can be performed abdominally or laproscopically.
• If MRI staging suggests cervical involvement, a radical hysterectomy
with pelvic node dissection can be performed.
• If tumour is high grade, pelvic and para-aortic node dissections will be
performed
2. Adjuvant therapy
• Post-operative radiotherapy will reduce the local recurrence rate but
does not influence survival.
• Strategies for treatment include local radiotherapy to the vaginal vault
given over a short period of time, external beam radiotherapy given
for locally advanced disease in combination with HDR.
• Chemotherapy may also be given for metastatic disease to combat
risk of distant spread of cancer.
Prognosis
• The overall five-year survival rate for endometrial cancer is 80%.
