SEMINAR

ON

GUIDE: CO-GUIDE:
DR. INDRA BHATI DR. HANSLATA GEHLOT
PRAMOTED BY :
DR. C.P. KACHHAWAHA

PRESENTED BY :
DR. DHARA
DR. S.N. MEDICAL COLLEGE,
UMAID HOSPITAL, JODHPUR (RAJ.)
Definition:-
 POSTMENOPAUSAL BLEEDING (PMB) is
vaginal bleeding occurring from the reproductive
system after twelve months of amenorrhea in a
woman of the age where the menopause can be
expected.
 MENOPAUSE: is the permanent cessation
of menstruation resulting from loss of
ovarian follicular activity. It can only be
determined after 12 months' spontaneous
amenorrhea (at least 6 month
amenorrhea ).
 Description: Menopause, the end of ovulation and
menstrual periods, naturally occurs for most women at
age 40–55 years. The process of ending ovulation and
menstruation is gradual, spanning one to two years.
 Postmenopausal bleeding is bleeding that occurs after
menopause has been established for at least six months.
It is different from infrequent, irregular periods
 (oligomenorrhea) that occur around the time of
menopause.
 Many women experience some postmenopausal
bleeding. However, PMB is not normal. Because it can
be a symptom of a serious medical condition, any
episodes of postmenopausal bleeding should be brought
to the attention of gynecologists.
 MENOPAUSE TRANSITION: 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
PERIMENOPAUSE: 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.
SURGICAL MENOPAUSE: occurs after bilateral
oophorectomy with or without hysterectomy.
 PREMATURE MENOPAUSE: may also be
radiation- or chemotherapy-induced, or occur
after hysterectomy with ovarian conservation.
 PRIMARY PREMTURE MENOPAUSE A

premature menopause is one that occurs

before the age of 40 years.
 Primary premature menopause may occur at
any age and present as amenorrhea. Not all
women have acute symptoms. FSH levels are
elevated. Spontaneous fertility may recur.
 Premature ovarian failure
(POF)
 Cessation of ovarian function at an early age.
 3 types
 These characterised by amenorrhea,
hypergonodotropic, hypo estrogenic.
 Type1 POF (Prepubertal ): ovarian failure
before puberty present as lack of pubertal
development & primary amenorrhea.
 HRT required for the induction of puberty,
maintenance of menstrual & sexual function.
 Type 2 POF (Postpubertal): present with
secondary amenorrhea with ovarian failure
before natural menopause.
 HRT required for the maintenance of
menstrual & sexual function.
 Type 3 POF : is iatrogenic occurs due to the
bilateral oopherectomy, chemotherapy,
radiation & stem cells transplantation for
malignancies.
Epidemiology: PMB is a common problem
representing 5% of all gynecology outpatient
attendances. More than ¾ are benign conditions
& less than ¼ are malignants.
AETIOLOGY: several causes are account for the
genital tract bleeding in a postmenopausal
women. Gynecology causes
1. Vulva- trauma, vulvitis, benign & malignant
lesions.
2. Vagina- foreign body, senile vaginitis, vaginal
tumor benign or malignant & post-radiation
vaginitis.
3. Cervix – cervical erosion, cervicitis, polyp,
decubitus ulcer in prolapse, & cervical
malignancy.
4. Uterus – senile endometritis, tubercular
endometritis, endometrial hyperplasia, polyp,
endometrial carcinoma & sarcoma mixes
mesodermal tumor.
5. Fallopian tube malignancy.
Aetiology
5 Ovary- benign ovarian tumor such as Brenner
tumor granulosa & theca cell tumor malignant
ovarian tumor.
Non gynecological causes
6. Hypertension, blood dyscrasia.
7. Urinary tract – urethral carnucle, papilloma and
carcinoma of urinary bladder may be mistaken for
the genital tract bleeding.
8. Bowel bleeding from hemorrhoids, anal fissure and
anal cancer may be misleading.
9. Anxiety & emotional stress.
 Incidence of causes of the postmenopausal
bleeding

 Atrophic vaginitis 60-80%.

 Polyps - endometrial or cervical 2-12%.
 Endometrial Hyperplasia5-10%.
 Endometrial Cancer 10%.
 Estrogen treatments 15-25%.
 No cause found 10%.
 Benign conditions is most
frequent causes of PMB but
endometrial cancer is the
most serious potential
underlying cause
 Staging of reproductive ageing
by STRAW
 ON THE BASIS OF RELATIONSHIP OF
FINAL MENSTRUAL PERIOD &
MENSTRUAL CYCLES WITH FSH
LEVELS.
 REPRODUCTIVE YEARS, MENOPAUSE
TRANSITION & POSTMENOPAUSAL ARE
DIVIDED INTO EARLY & LATE.

STRAW Stages of reproductive

aging workshop
 MENOPAUSE STAGING
 STAGE I: earliest perimenopausal symptoms
to menstrual cessation.
 Last for 3 to 5 years.
 It may IA :- vasomotor instability.
 II B:- psychosomatic symptoms
 Required palliate treatment.
 Stage II:- five years after menopause.
 IIA- 1 year. Main symptom are vasomotor
instability & urethral sympyoms.
 II B : from end of IIA upto next four year.
common issue are
 Atrophic symptoms

 Urinary symptoms

 Weight gain

 Skin hair changes

 Genital prolapse

 Psychological symptoms etc.

 Stage III from 5 years after menopause upto
onwards
 III A residual atrophic symptoms
 III B stage of IHD & osteoporosis.
 III C very late complications.
 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).
 Path physiology
 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.
 Hormonal changes in menopause
Anterior GnRH hypothalamus
pituitary

Finally FSH LH

Oestradiol inhibin B
Adipocyte
Main
hormone
ovary Follicular atressia Oestradiol, oestrone

Androstenedione Androstenedione, DHEA, testosterone,DHEAS

Adrenal
gland
 Choronology of age
related oestrogen production

Fetal life ovaries No estrogens

Adolescence Estrogen production Peripheral effects

Folliculogenesis & Regular menstruation

Reproduction age
ovulation
Fertility

Decrease in
Perimenopause Reduced follicular reserve Short cycles
estrogen

No estrogen
Follicular exhaustion Amenorrhoea
Menopause & progesterone
& no ovulation
Peripheral effect of
estrogen withdrawal
Postmenopausal Atrophic changes
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.
4. Women taking tamoxifen & clomifen
SIGN & SYMPTOM

 Vaginal bleeding, the predominant symptom

 Ranges from spotting to outright hemorrhage.
 Its duration also varies.
 Estrogen deficiency may cause the vaginal
mucosa to shrink.
 Abdominal pain
 Approach for the patients of
postmenopausal bleeding
 History – age of menarche
menstrual history flow & duration
age of menopause
history of IUCD and pessary
taking estrogen & tamoxifen.
prolapse to be elicited.
Abdominal pain
foul smelling discharge (malignancy)
Urinary & rectal symptoms to be elicited.
evening rise of temp
family h/o genital tract carcinoma
Clinical examination

 Blood pressure
 General examination include obesity, diabetes which are
prone to endometrial cancer.
 Breast examination.
 Abdominal examination- Lump abd, pyometra, ovarian
tumors , adenexal masses,and visceromegaly for
evidence of secondries
 Speculum exami-senile veginitis, growth and ulceration .
cervical erosion, growth, polyp & ulceration
 Per vaginal examin-size of uterus, adenexal mass details.
 Investigations
 Excluding the malignancy is the main aim of
investigations.
 Hemograme with PBF
 RBS, RFT, LFT,
 Cervical cytology for the cervical lesion (Pap
smear) and endocervical sampling
 Colposcopy and directed biopsy
 Endometrial study
 Fractional curettage
 Hormone blood level.
Investigations
 USG & TVS-(post menopausal uterus is 3-7 cm
length,1-2 cm thick)(endometial echo complex
less then 5 cm thick and regular). See secondaries
.
 Sonohysterography -d/d of end. hyperplesia and
polyp
 Hysteroscopy and directed biopsy
 Trans veginal pulsed doppler ultrasound-decresed
pulsatility index in ca uterus
 CT-better evaluation of the deep pelvis and pelvis
side walls ;disadvantage risk of ionizing radiation
 MRI-image in multiple planes so better
evaluation. advantage lack of ionizing radiation .
TVS:- is screening tools
•As TVS 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 endometrial
thickness is > 5mm thickness is < 5mm

follow
If low risk If high risk

D/C biopsy OR But symptoms

office endometrial hysteroscopy persist
biopsy and SIS

In women with continued bleeding after a negative initial evaluation, further testing
,with hysteroscopically directed biopsy is essential
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

catheter
With polyps the endometrial-myometrial POLYP
interface is preserved
 The Thickened endometrium may be a
polyp
CYST

POLYP

With polyps the endometrial-myometrial

interface is preserved well-defined, homogeneous,
isoechoic to the endometrium
CONVENTIONAL MEDICAL TREATMENT 
 Specific therapy, usually medications or surgery, is dependent
on the cause. 
 Hormone related post-menopausal bleeding is usually
controlled by manipulation and alteration of hormone
[Link] progesterone in ERT .Annual TVS for endometrium
thickness or endometrium aspiration cytology in ERT taking ladies.
 DILATION & CURETTAGE (D&C):
 HYSTEROSCOPY:
 HYSTEROSCOPIC & RESECTOSCOPIC ENDOMETRIAL
ABLATION 
 UTERINE BALLOON ABLATION
 HYSTERECTOMY 
SURGERY-If the [Link] to have persistence of bleeding
per vaginum Laprotomy is justified as small functional ovarian
tumour may not produce ovarian enlargement and carcinoma
of the tubes may not be detected by any of the diagnostic tools
at our disposal. 
 Complications
 Profuse bleeding can cause anemia.
 Prolonged use of estrogen replacement
therapy (ERT) that is not combined with
progestin increases the risk of endometrial
hyperplasia and endometrial cancer in women
who have not had a hysterectomy.
 Cancer, both endometrial and cervical, can
spread to other areas of the body.
Prognosis
 Outcome depends on the cause of the bleeding, and can range
from complete cure to death from cancer.
 A simple dilation and curettage (D&C) procedure may
completely stop postmenopausal bleeding.
 Polypectomy will relieve any bleeding associated with the
presence of polyps. Endometrial hyperplasia is usually resolved
by administering progestin for 3 months.
 Estrogen replacement therapy (ERT) with progestin usually
prevents additional abnormal postmenopausal bleeding.
 A hysterectomy will permanently cure endometrial hyperplasia
with atypical cells, uterine fibroids, bleeding, and anemia.
 The outcome of a hysterectomy, as treatment of cancer of the
endometrium (uterus) or cervix, depends on the extent of tumor
spread.
 The outcome of endometrial and cervical cancers that are
diagnosed early is very good.