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Home , Endometrial polyp

10 Uterine Bleeding in the Postmenopausal Period

Heleen van Beekhuizen

INTRODUCTION bleeding) of the . It is more fre- quent in women with or a long history in the postmenopausal period is of polycystic ovary syndrome (see Chapter 16 always abnormal and needs detailed history taking, on subfertility) and anovulatory cycles. Hyper- speculum examination and bimanual vaginal exam- plasia with atypical cytological features is more ination. Many women need additional tests like likely to progress into uterine (25–40%) visual inspection with acetic acid (VIA) and ultra- than hyperplasia without atypi cal cytological sound to rule out cervical (pre)malignancy and features that becomes malignant in only a few endo metrial cancer or bleeding from other sources patients. (rectal, urinary tract). • Endometrium : this is a benign growth of the inside lining of the , the endometrium. Definition Sometimes the polyp is ‘born’ and visible on A woman is postmenopausal if her periods have speculum examination. stopped for 12 months. • Cervical cancer: bleeding and foul smelling dis- charge are common symptoms. In advanced cases is prominent. CAUSES OF POSTMENOPAUSAL VAGINAL • Endometrial cancer: blood loss is often the first BLEEDING sign. It is very uncommon in women below • Atrophy: the cells of the urogenital system have the age of 40 years, but in all postmenopausal receptors. After the the women with bleeding problems it should be uro genital system becomes atrophic and the considered. becomes dry, pale, narrow, loses its elasti- • Uterine sarcoma: a highly malignant tumor of the city and bleeding can occur. Other symptoms uterus is more common in black women. Blood are (pain during intercourse), urine loss, pain and abdominal mass are the most fre- incontinence or urinary frequency (frequent quent symptoms. Sarcoma can present pre- or need to urinate) or . postmenopausal but is rare. • Urogenital prolapse: this can cause friction and • Granulosa cell tumors of the ovaries: these produce ulceration leading to postmenopausal blood loss. estrogen and cause and • Forgotten (IUD): sometimes dysfunctional uterine bleeding (DUB) or post- women present with an old IUD in the uterus menopausal vaginal bleeding. for a long period. This can cause vaginal bleed- • Urogenital schistosomiasis: this can cause abnormal ing due to infection. Treatment is simple: re- bleeding in postmenopausal women and can move the IUD. mimic cervical cancer. • Hyperplastic endometrium: atypical hyperplasia can be a pre-stadium of endometrial cancer and is HISTORY TAKING caused by unopposed estrogen stimulation (without progesterone that causes withdrawal • Age of menopause and duration of postmenopause.

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• Pregnancies and periods before menopause metrium cells in a PAP smear is abnormal and ( regular cycles?). needs endometrial tissue sampling (see below). • Duration and frequency of bleeding. • Ultrasound: you can detect thickened endo- • Symptoms of atrophy (dryness of the vagina, metrium (polyps, hyperplasia, endometrial can- dyspareunia, dysuria) or prolapse present? cer), fibroids and ovarian masses. A useful cut-off • Vaginal discharge. point for thickened endometrium is around • Abdominal swelling or pain. 3–4 mm in postmenopausal women. • Sexual history: sexually transmitted infections • Biopsy for histology if suspicion of cervical or (STIs)? endometrial carcinoma. A cervical biopsy can be • Contraception before menopause (IUD)? obtained using a special cervical biopsy forceps and can detect cervical cancer in almost 100% and genital schistosomiasis in about 50%. For EXAMINATION endometrial sampling (do this in postmeno- pausal women with thickened endometrium • Obesity: women with morbid obesity [body >3–4 mm on ultrasound) you could use the mass index (BMI) >30; see Chapter 8 on how to smallest cannula of a manual vacuum aspiration calculate BMI] have a high level of estrogen. (MVA) set (see Chapter 6) or perform a dilata- • Speculum examination: tion and curettage (D&C). The big advantage of N Signs of atrophy: pale, dry vagina sometimes a MVA is that you can perform this without with petechia (small red spots caused by sub- anesthesia in most women. The advantage of mucosal bleeding). D&C is that if postmenopausal blood loss is N Prolapse with pressure sores? caused by endometrium polyps the D&C can be N Cervical carcinoma? therapeutic. Make sure you can send the sample N Vaginal discharge? ? to a place where histology can be done within a N Endometrial polyp visible in vagina? reasonable time. N If possible perform a test for pre-stadia of • is an advanced diagnostic test: cervical cancer like a human papillomavirus with a scope you can inspect the inside of the (HPV) test or a VIA; see Chapter 26. uterus. In many low-resource settings this is not N Presence of grainy sandy patches – alterations available yet (see Chapter 1). are considered to be characteristic of schisto- somiasis in the . N IUD thread. • PVE: fibroids or pelvic masses? If you suspect TREATMENT advanced cervical carcinoma do a rectal exami- Endometrial malignancies need a nation as described in Chapter 1. with removal of ovaries (see Chapter 26 and Chap- If you cannot find a plausible benign cause of post- ter 19 for TAH; Chapter 20 explains how to do a menopausal blood loss the woman should undergo vaginal hysterectomy). two tests: first an ultrasound to measure the thick- Hyperplasia with atypia needs a hysterectomy ness of the endometrium and to look for pelvic while hyperplasia without atypia can best be treated masses and secondly a test to exclude a premalig- with a (LNG)-IUD (Mirena®). nancy of the cervix (HPV or VIA). Second-best therapy is oral progestogens like medroxyp rogesterone acetate (10 mg/day for 3 months). In both cases repeat the sampling of the ADDITIONAL TESTS endometrium after 3 months. When performing an • HPV or VIA tests to screen for pre-stadia of cer- MVA after 3 months you can leave the IUD in situ! vical cancer (see Chapter 26). If you work in a Polyps protruding through the cervix can be facility in which a PAP smear can be made this grasped with a sponge-holding forceps and you can is a useful test in postmenopausal bleeding: you twi st them off. can detect pre-stadia of cervical cancer as well as Atrophy of the vagina can be treated with topi- the presence of (abnormal) endometrium cells. cal estrogen cream, for example estriol cream 2–3 In postmenopausal women presence of endo- times a week.

97 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS stage to tissue sampling Abnormal cervical Abnormal cervical US: endometrium

4 mm: do endometrial cancer screening test: treat according

ш human papilloma virus test; seen PAP) No abnormalities Do US and cervical Do US and cervical screening (HPV, VIA or screening condition to or ovaries: treat or ovaries: after 2 months < 4 mm: review < 4 mm: review

US: endometrium according US masses of uterus US masses

Take biopsy Take biopsy and possible cervical possible cervical Abnormal cervix: treat according stage cancer or schistosomiasis peculum, s Twist polyp of polyp Twist Postmenopausal using a If forceps. possible histology Endometrial polyp Bleeding: do vaginal examination and examination vaginal screen for cervical screen for cervical cancer ) 25 Prolapse possible treat possible possible treat Explain and if Explain and if Explain (see chapter (see Chapter 23)

of vagina y treatment) Atroph (see paragraph on Treat with Treat with cytological smear for detection of pre-stadia cervix cancer; HPV, Flowchart for management of postmenopausal bleeding. PAP, US, ultrasound; VIA, visual inspection of cervix with acetic acid Figure 1 Figure

98 Uterine Bleeding in the Postmenopausal Period

For granulosa cell cancer, please see Chapter 28 World Health Organization. Report of an informal working and for prolapse Chapter 23. group on urogenital schistosomiasis and HIV transmission. WHO/HTM/NTD/PCT/2010.5. Geneva: WHO, 2009 FLOWCHART: POSTMENOPAUSAL Kaur J, Dey P, Saha SC, et al. Cervical cytology in patients BLEEDING with postmenopausal bleeding. Diagn Cytopathol 2009; 38:496–8 All women with postmenopausal bleeding should Timmermans A, Opmeer BC, Khan KS, et al. Endometrial have detailed history taking and full gynecological thickness measurement for detecting endometrial cancer in examination (as in Chapter 1): do speculum, vagi- women with postmenopausal bleeding: a systematic review nal examination and screen for pre-stadia of cervi- and meta-analysis. Obstet Gynecol 2010;116:160–7 cal cancer (Figure 1). Gallos ID, Shehmar M, Thangaratinam S, et al. Oral pro- gestogens vs levonorgestrel-releasing intrauterine system FURTHER READING for endometrial hyperplasia: a systematic review and meta- analysis. Am J Obstet Gynecol 2010;203:547e1–10 Marret H, Fauconnier A, Chabbert-Buffet N, et al. Clinical practice guidelines on menorrhagia: management of abnor- mal uterine bleeding before menopause. Eur J Obstet Gyne- col Reprod Biol 2010;152:133–7

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