Transcript Post menopausal bleeding pv

Post-menopausal bleeding PV
Dr Nasira Sabiha Dawood
Menopause
• Menos month
• Pausis
cessation last menstrual period
• Climacteric ladder the climb to the
menopause
Menopause demographics
• Life expectancy of women has increased to
82 years
• 200 years ago only 30 % women lived
through menopause and post menopause
• Post menopause is a condition of 20th and
21st centuries
• Age of menopause is constant
Phases
• Reproductive regular cycle normal FSH
• or raised in late phase
• Perimenopause heavy or oligomenorrhic till
one year after FMP raised FSH
• POST MENOPAUSE one year after FMP till
death
POSTMENOPAUSAL BLEEDING PV
–vaginal bleeding
–after twelve months of
amenorrhoea
–woman of the age where the
menopause can be expected
–younger women premature
menopause
Epidemiology
• a common problem
• 5% of all gynaecology
outpatient attendances
• 30 % of postmenopausal
women
Causes - Benign
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Unopposed estrogen
Atrophic vaginitis
Atrophic endometritis
Endometrial polyps /cervical polyps
Endometrial hyperplasia
Others
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–
–
–
–
Weight loss
Emotional stress
Trauma, bleeding disorders
Hormone replacement therapy (HRT)
Tamoxifen
30%
30%
10%
5%
10%
Causes - malignant
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Endometrial cancer
Uterine sarcoma (rare)
Carcinoma of cervix
Ovarian carcinoma
15%
Oestrogen-secreting (theca cell) ovarian tumours
• Vaginal carcinoma (very uncommon)
• Carcinoma of vulva
may bleed, but lesion should be obvious
Management
• postmenopausal bleeding should be taken
as malignant, until proved otherwise.
management
• History
• General physical /systemic
• PELVIC EXAMINATION
management
• Investigations
– Blood complete picture
– Urine RE
– Blood glucose
– Liver functions
– Renal functions
– Viral serology
– X-ray chest
– ECG
• Cervical smear
• USS
• Biopsy
Investigations
• Transvaginal Ultrasound Scan(TVS)
–first-line procedure
–Women at higher risk of endometrial
cancer
–endometrial thickness <5
• thickness of >5 mm gives 7.3% likelihood of
endometrial cancer
Investigations
• Endometrial biopsy
– definitive diagnosis by histology
– dilatation and curettage
• Hysteroscopy
– to detect polyps and other benign lesions
– as an outpatient procedure
– some women will require GA
– 'one stop' specialist clinics
several investigations are available to complement clinical
evaluation, including ultrasound, endometrial sampling
techniques and hysteroscopy
treatment
• Atrophic endometrium
no treatment
• Atrophic vaginitis
vaginal estrogen creams
• Uterine polyps
removed, can change to cancerous condition
• Uterine fibroids
shrink after menopause, enlarge or associated with PMB –
removed because of potential malignant change
• Endometrial hyperplasia
– simple treated with medicines
– atypical requires surgery
Study of PMB at FFH RWP
• Objective
To determine the frequency and types of malignant
tumors of genital tract among post menopausal
women complaining of vaginal bleeding
• Design
•
Descriptive
Materials and Methods
• Patients
• Included
141
– Postmenopausal for 1 year
• Excluded
– On hormone therapy
Radiotherapy or chemotherapy
– Hysterectomy
– Trauma to the genital tract
Women having coagulation disorder
Results
• Total cases
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141
Uterine pathology
Cervical pathology
Ovarian pathology
Vaginal pathology
97
27
06
01
Histopathology
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Uterine Total
Proliferative endometrium
Secretory endometrium
Cystic hyperplasia
Disordered proliferation
Adenocarcinoma
Endometrial polyp
Necrosed decidua
• Atrophic changes
97
28
13
7
3
13
6
3
24
Histopathology
• Ch non specific endometritis
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Pyometra
leiomysarcoma
Fibroid uterus
Tuberculosis
Decubitus ulcer
2
4
1
1
1
1
Histopathology
• Cervix
Total
• chronic cervicitis
cervical polyp
Cervical ectopy
CIN 1
Ca Cervix
•
sq cell ca
•
adeno ca
27
9
7
4
2
5
4
1
Results
Age distribution
44-49
50-59
60-69
70-79
80
TOTAL
11
72
36
20
2
141
15.5 %
101.52 %
50.76 %
28.2 %
2.82 %
Frequency of cancers
– Total cases
– Ca endometrium
– Ca cervix
– Ca ovary
– Ca vagina
25/141
13
5
6
1
– Overall frequency of cancer
18.3 %
7.05%
8.46%
1.41%
32.25 %
Histopathology
• Ovary
Total
• Granulosa cell tumor of ovary
• Mucinous cystadenocarcinoma
• Papillary cystadenocarcinoma
7
3
2
2
Histopathology
• Ca vagina sq cell carcinoma
1
Age distribution in cancers
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Ca endometrium
Ca cervix
Ca ovary
Ca vagina
49-75 yrs
59-71 yrs
54-69
73yrs
Time since menopause
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Ca endometrium
Ca cervix
Ca ovary
Ca vagina
1-20 yrs
1-11 yrs
1-25 yrs
22 yrs
Size of uterus
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• Ca endometrium
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bulky
atrophic
10
3
Conclusion
• All patient presenting with post menopausal
bleeding PV how much slight or brief need to
be investigated and treated
• Time since menopause is not important
though more cases of atrophic vagintis and
endometrium were seen in older age group
• Asymptomatic patients with bulky uterus
need to be investigated on the same lines as
PMB
•
THANK YOU