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Postmenopausal Bleeding of Nonmalignantorigin Postmenopausal Bleeding of Nonmalignant Origin EDWARD J. BOMZE. M.D., Los Angeles VAGINAL BLEEDING after completion of the meno- * A study was made of the medical records of pause is usually viewed with alarm by patients and 102 patients hospitalized because of postmeno- physicians. Even a relatively uninformed woman pausal bleeding. Diagnostic procedures used senses the ominous implications and seeks advice included vaginal examination, Papanicolaou and reassurance. It is quite generally accepted and smears, curettage and cervical biopsy. taught to both the medical profession and the lay The major associated pathological conditions public that vaginal bleeding coming on after the (possibly etiological factors) in the series were menopause must be considered as owing to malig- chronic cervicitis, fibromyoma of the uterus, nant disease unless proven otherwise. Yet it is easier endometrial polyps, cervical polyps and adeno- to demonstrate the presence of a malignant tumor if myosis of the uterus. Sclerosis of the uterine one exists in a given patient than it is to be certain vessels was suggested as another possible cause there is no malignant lesion even though results of of this type of bleeding. Neither the amount diagnostic procedures are all negative. Even when and type of bleeding nor the pattern of associ- comprehensive examination elicits no evidence of ated symptoms were of diagnostic value. carcinoma, the disturbing thought frequently re- A history of hormonal therapy prior to the mains that complete removal of the uterus and onset of bleeding is not sufficient evidence to adnexa might disclose an early malignant tumor. establish that as the cause of the bleeding and Since this situation, disturbing to both patients the patient should be as comp/etely investi- and physicians, is encountered frequently not only gated as if this history were not present. by gynecologists but by general surgeons and gen- In over 61 per cent of cases in this series, eral practitioners, further inquiry into the benign uterine cureffage with or without cervical causes of bleeding at this period of life would seem biopsy, cauterization, conization or trachelor- worth while. It would be very comforting to the rhaphy, was the only treatment required for patient if she could be told with confidence that there both diagnosis and therapy. are a number of specific benign conditions which can cause bleeding after the menopause. With this purpose in mind, the author reviewed the records of tuted promptly after the patient consulted a phy- 102 patients who were admitted to hospital because sician. of postmenopausal bleeding and in whom no evi- The amount and duration of bleeding was not of dence of malignant disease was found after careful any particular diagnostic value but there was a sug- investigation. Some useful concepts were suggested gested relationship between the amount of bleeding by this 'study. and the type of lesion. In general, bleeding caused The patients were from 39 to 81 years of age. by minor lesions of the vagina and cervix in this More than 60 per cent were between the fiftieth and group of patients consisted mainly of bloody dis- sixtieth years. The interval that had passed between charge or spotting. Bleeding of large amount was cessation of menses and the occurrence of bleeding in the majority of cases associated with disease in the ranged from four months to 30 years. There was no endometrium or uterus. However, these coincidences significant coincidence of onset of bleeding and were not sufficiently constant to be considered diag- length of time since cessation of menses. nostic criteria. The amount of bleeding varied. In some instances In only 10 of the 102 records was there reference it was described as a pink or brown discharge or to hormone therapy and its relation to the bleeding "spotting"; in others, as repeated or continuous under consideration. In seven cases it was said spe- vaginal bleeding, occasionally so profuse as to be cifically in the history that the patient had been called hemorrhage and to be associated with a low treated with estrogens or some hormone preparation hemoglobin content in the blood when the patient before or concurrently with the bleeding. In three entered the hospital. The duration of bleeding before cases it was stated that the patient had not had the patient entered the hospital varied from one day hormone therapy. Although in the other 92 records to as 'long as four years (intermittently). It was no reference was made to the question of hormone noted that in all except two or three cases surgical therapy, it is more than probable that this factor measures for diagnosis and treatment were insti- was considered, for the patients were otherwise care- VOL. 81. NO. 2 * AUGUST 1954 69 fully studied. Data included in the office records of TABLE 1.-Pathologic diagnoses In 102 cases of postmenopausal a patient are not always entered in the hospital vaginal bleeding not caused by malignant disease charts, most of which are written by externs and Diagnosis No. Remarks interns. It was impractical to interview all the indi- Chronic cervicitis...................... 38 4 with ulceration vidual attending physicians. In any case, the infor- Fibromyoma of uterus ..... 23 mation so obtained would have been of doubtful Endometrial polyps............................... 21 value since it would be hazardous to ascribe vaginal Cervical polyps.............................. 19 Endometrial hyperplasia.. ... 12 bleeding to hormone effect on the basis of the history Adenomyosis uteri................... 10 alone, without further investigation as to other Fibrosis of uterus..... 10 possible causes, for a patient who has had hormone Erosion of cervix..........7... 7 Cystic glandular hyperplasia of cervix.... 5 therapy can also bleed from other causes. Squamous metaplasia of cervix, mild ...... 2 Only about one-third of the patients had asso- Squamous metaplasia of endometrium 1 Chronic vaginal ulcer 1Non-specific ciated symptoms or complaints-feeling of pressure Fibro-epithelial papilloma....................1..........of vagina 1 in the lower abdomen, lower abdominal cramps, Theca cell tumor of ovary.................... 1 Benign histo- logically mild backache, suprapubic discomfort, headache, "Foci of necrosis in endometrium with soreness of the breasts, and a feeling of irritation in deciduoid reaction in stroma"................1 the vagina and vulva. These complaints appeared to Hyperkeratosis of cervix................5........... 5 bear no relation to the actual cause of the bleeding. No definite pathologic diagno,is.............. 12 The diagnostic procedures used in this series of cases, in addition to pelvic examination, consisted of Papanicolaou smears, uterine curettage, biopsy of year-old patient who was two years past the meno- the cervix, and biopsy of the vagina. pause was reported as showing "foci of necrosis The pathologist's reports in these cases showed a suggesting a postparturient reaction, with a decidu- fairly large variety of lesions (Table 1). The most oid reaction in the stroma" - a diagnosis which frequent pathologic diagnosis was chronic cervicitis, could be explained similarly on the basis of hor- associated in some instances with ulceration or ero- monal effect. sion of the cervical epithelium. Next most common There were two instances of mild squamous cell were fibromyomata of the uterus (almost all of them metaplasia of the cervix and one of "squamous cell submucous) and single and multiple fibroid tumors. metaplasia of the endometrium." It may be that the Endometrial polyps were observed almost as often lesions in these three cases are early carcinoma in as fibroid tumors and in a fair number of instances situ, but the question has not been resolved as yet, were associated with them. The general impression for the patients all had curettement within the past at present seems to be that cervical polyps are the year and a half and none has had any further bleed- most frequent cause of bleeding from nonmalignant ing. lesions after the menopause. However, this diagnosis In many of the cases in which the uterus was re- was recorded in only 20 per cent of the cases in this moved, sclerosis of the uterine vessels was noted in series. the pathologist's report. The observation was made Adenomyosis was the diagnosis in approximately often enough in this series to suggest the possibility 10 per cent of these patients. In a number of in- that sclerosis may in some way have been an etio- stances it was associated with fibroid tumors; in the logic factor in the bleeding that occurred from senile remainder it was either the only causative factor or atrophic uteri, many of which, on preliminary cu- was accompanied by minor lesions. This is surpris- rettement, did not yield sufficient endometrial tissue ing for two reasons. First, adenomyosis is not gen- for microscopic study. erally thought of as a cause of uterine bleeding; In 23 cases, treatment consisted of simple dilata- second, adenomyosis and endometriosis are believed tion and curettage; in 41, curettement was combined to undergo involution at the time of the menopause. with biopsy of the cervix; and in five, biopsy of the The mechanism by which adenomyosis can produce cervix with or without coni- uterine bleeding is not clear and should certainly was done cauterization, be studied further. zation, or trachelorrhaphy. One patient had cervical In 12 cases the diagnosis was endometrial hyper- amputation; 39 had hysterectomy, done vaginally or plasia. Eight of the women with this diagnosis had abdominally, with bilateral salpingo-oophorectomy completed the menopause eight months to four years also in most cases. previously, and four had not menstruated for 17 to Follow-up information was obtained on about 50 30 years. None of these women had a history of hor- per cent of the patients. The remainder were either mone therapy, but it is difficult, on the basis of ac- too recently treated for evaluation or were no longer cepted theories of the menopause, to account for in conmmunication with the physicians who attended hyperplasia in the absence of female sex hormones them.
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