Abnormal uterine bleeding including postmenopausal bleeding pdf - غير معروف

hysterosalpingography

Asherman`s syndrome) can be a cause and diagnosed by a

be the cause. Uterine synechiae

vical stenosis may

such as hymenal or cer

only spotting. An obstruction

Sometime

scanty menstruation.

rhoea:

Hypomenor

indication of malignant tumors or pregnancy complications.

lead to menometrorrhagia. Sudden onset of irregular bleeding episodes may be an

Any cause of intermenstrual bleeding can

amount and duration of bleeding also vary.

The

gular intervals.

eeding at irre

Prolonged or excessive b

Menometrorrhagia:

Exogenous estrogen may be a cause.

Endometrial polyps, endometrial and cervical carcinomas are pathological causes.

occurs at midcycle as spotting and can be documented with basal body temperatures

ying amounts but not excessive. Ovulatory bleeding

of var

regular menstruations

episodes of uterine bleeding between

ual bleeding

Intermenst

rhagia

Metror

may be the cause.

mors and dysfunctional bleeding

hyperplasias, malignant tu

IUCDs, endometrial

ions of pregnancy, adenomyosis

, complicat

fibroid

Submucous

coital bleeding.

over several consecutive cycles without any intermenstrual or post

ntervals

Excessive (>80 ml) & / or prolonged menstruation, at regular

Menorrhagia:

n the menstrual cycle.

luteal phase i

lation and rarely with a shortened

This is usually is associated with anov

intervals

regular

Described periods that occurs too frequently (<21 d)

Polymenorrhoea:

CLINICAL TYPES

80 ml

Volume: 30

Duration: 3

Frequency: 21

ENSES

NORMAL

and cervical cancer.

fibroid

uterine

eg.

than one entity may be present, such as

d, and always remember that

complication of pregnancy must always be considere

ina, urethra, or rectum. In child bearing women, a

of the bleeding from the vag

most difficult problems in gynecology. Patient may not be able to localize the source

ne bleeding present some of the

The diagnosis and management of abnormal uteri

reproductive age.

truation in women of

Any deviation in normal frequency, duration or amount of mens

DEFINITION:

general practitioner

Abnormal uterine bleeding is a common reason for women of all ages to consult their

the management options of AUB.

Analyze

g to specific age group.

Correlate the cause of bleedin

Determine the causes behind HMB (heavy menstrual blood loss).

Describe the causes of ABU.

List the clinical types of AUB.

Define AUB.

Learning objectives: By the end of this lect. You need to:

(AUB)

bnormal uterine bleeding

•

-35 d

•

-7 d

•

(

Genital disease:

disease, placenta previa and abruptio placenta.

Abortion, Ectopic pregnancy, Trophoblastic

Pregnancy complications:

Dysfunctional uterine bleeding

of AUB:

USES

necessary.

invasive cancer, and colposcopy, biopsy, or both may be

not rule out

smear does

negative cytological

vaginal infection (eg, trichomonas), or atrophic vaginitis. A

her much common causes are cervical erosion, cervical polyp, cervical or

otherwise, ot

must be considered as a signs of cervical cancer until proved

Postcoital bleeding

causes, menopause) or systemic causes ( eg, excessive weight loss).

hypothalamic

, either from endocrine cause (eg, pregnancy, pituitary

novulation

iated with

assoc

. Usually

no menstrual period occurs for more than 6 months

is diagnosed if

amenorrhoea

(but

infrequent menstruation (>35 d)

Oligomenorrhea:

flow and can be reassured that this is not significant.

ral contraceptives occasionally complain of light

hysteroscope. Patients received o

)

d), adenomyosis.

Benign: fibroid, polyps (cervical, endometrial, fibroi

Tumors:

secreting)

Malignant: cervical, endometrial, ovarian (estrogen

PID, cervicitis and endometritis.

Infection:

foreign

: laceration, abrasion

Trauma

body.

IUCD

genital:

Extra

g's disease, Polycystic

mia, Cushin

thyroidism, Hyperprolactine

Endocrine

: hypo

Willebrand disease,

: Idiopathic thrombocytopenic purpura, Von

Haematological

syndrome, Adrenal dysfunction/tumor.

varia

: liver failure, renal failure, hypertension with uterine

Chronic systemic disease

therosclerosis.

artery a

( progestogen only contraception, IUCD)

: Sex hormones

Iatrogenic

anticoagulants.

: may be emotional as (change of country, climate & work; psychosomatic

Stress

disorders) or may be due to excessive exercise.

eripheral estrogen conversion]

: [increased p

Obesity

New classification of abnormal uterine bleeding:

dysfunctional uterine bleeding

Bleeding of endometrial origin (replace

eplace menorrhagia).

HMB

Heavy menstrual bleeding

Prevalence and impact:

the leading indication for hysterectomy

and

system, being one of the most frequent indication for abstinence from work

complaint result in significant morbidity, has economical burden on the health

1/ 3 women of reproductive age. This

affects

HMB

ding

Heavy menstrual blee

(

)

Causes of HMB :

usually associated with submucosal and intramural fibroids.

Fibroids:

with

are common and sometime cause intermenstrual bleeding

Polyps:

uterine fibroids.

polypoidal

increased volume of bleeding with

systemic

n with HMB will have

% of wome

: around 10

Coagulopathy

-20

thrombocytopenia.

cquired condition as sever

ent. A

oung age or not respond to medical treatm

in 13% of women with HMB which should be considered in those present at

mild to moderate), especially von Willebrand’s which found

rder varies (

diso

disorder of haemostasis, which are inherited or acquired and the severity of

potential cause of

carcinomas are

Both endometrial and cervical

Malignancy

bleeding.

abnormal

premalignant condition also may present with

hyperplasia which is

and rarely HMB. Endometrial

intermenstrual and postcoital bleeding

that typically

cause anovulation

idis

hypothyr

Untreated

Thyroid disease:

present with amenorrhoea but sometime associated with HMB.

with abnormal

iate

assoc

chronic endometrial infection may

Pelvic infection:

could be a cause of HMB

uterine bleeding both intermenstrual and heavy. Chlamydia Trachomatis

which are congenital or acquired

(AVM)

Arteriovenous malformation

diagnosis.

curettage after pregnancy. Colour Doppler imaging may be helpful in the

Congenital AVM are rare but acquired type may follow uterine

bleeding.

occur in the uterus they have been associated with episodes of acute excessive

When they

veins

localized collection of abnormally connected arteries and

an with thromboembolic

ing anticoagulant drugs in wom

like us

Iatrogenic:

inflammatory process).

he effect is through the local

cupper intrauterine contraceptive devices (t

ovarian axis) and

pituitary

hypothalamic

by prolactin related disruption of

disorder, tricyclic antidepressants and phenothiazines which affect ovulation

(

–

in the majority of the cases of HMB, it is

Bleeding of endometrial origin:

prostaglandins, endothelins and nitric oxide.

and include

regulate vascular tone inside the uterus may play a role

by exclusion. The exact endometrial mechanism still unknown, factors which

which is diagnosed

previously called DUB (dysfunctional uterine bleeding

probable that the bleeding lies at the level of endometrium itself. This

)

50 %.

HMB and reduce blood loss by 40

fibrinolytic activity so antifibrinolytics commonly prescribed for complaint of

having increase

omen with HMB

lesser need for coagulation. W

e is

ther

Since menstrual loss is mainly controlled by vasoconstriction

HMB

inhibitors is the first line treatment during menses for women with

Cyclooxygenase

the endometrium of women with HMB so administration of

crease level of prostaglandins

arly researches in this field demonstrate in

(COX)

Summery for the causes of HMB

Don’t forget iatrogenic causes.

Malignancy should always be excluded.

20% of cases

athies may account for 10

Coagulop

In most women no cause will found.

al uterine bleeding in premenopausal women

of abnorm

Anovulation and its related progesterone deficiency is the leading cause

likely

most

bleeding of endometrial origin

f normal physical exam, anovulatory

Hematologic

PCOS

infection

Adenomyosis

Fibroids

Polyps

Pregnancy

Anovulation (90%)

Etiol

identifying the etiology of anovulation.

secondary to anovulation, and the diagnostic investigation is targeted at

origin

bleeding of endometrial

the most likely diagnosis is

ultrasound will be needed,

cytological examination and pelvic

ination,

normal findings on physical exam

with

the pathological causes are not common

In premenopausal women

menopausal AUB

Pre

performed to exclude pregnancy or pathological conditions

amination not possible in case she is unmarried, so pelvic ultrasound must be

and pelvic

Invasive diagnostic procedures are usually not necessary

needed.

treatment that is necessary. But if the bleeding is heavy then treatment will

s all the

, and explanation of the reason i

So the menses not unusually are irregular

Infection

Medical illnes

von Willebrand’s

, e.g.

menorrhagia have a bleeding disorder

Up to 20 % presenting with

Hematological

Pregnancy

Anovulation (90%)

Adolescents

Sexual abuse

Precocious puberty, neoplasm

Rare

rologic

Trauma, FB, vulvovaginitis, u

Most common :

Always abnorma

Menarchal

Pre

menopausal

Post

menopausal

Peri

Adolescence & later

menopausal

Pre

menarchal

Pre

Approach based on age

AUB:

–

•

–

•

–

•

–

•

–

•

ogy

–

– IUCD

• I

How:

4. Impact of the bleeding on the woman’s quality of life.

Ovulatory or anovulatory

Exclusion of organic causes

Nature & severity of bleeding

Aim:

of AUB

Diagnosis

( Hormone replacement therapy)

Fibroids

cervical c

hyperplasia

Endometrial

Atrophy of vagina, EM

carcinoma

Endometrial

Etiology

initial investigation.

group, endometrial biopsy or transvaginal ultrasonography is included in the

menopausal women with abnormal uterine bleeding. Thus, in this age

post

Uterine pathology, particularly endometrial carcinoma, is common in

menopausal AUB

Post

cancer

Endometrial

hyperplasia

Endometrial

Anatomic (fibroids, adenomyosis, polyps)

Anovulation

Etiology

therapy started.

hould be assured before hormonal

. And the cause of bleeding s

investigation

endometrial hyperplasia or carcinoma must be considered early in the

In perimenopausal patients, endometrial biopsy and other methods of detecting

menopausal AUB

Peri

•

–

•

–

– HRT

. History

Sexual history, contraceptive use and fertility wishes need to be determined.

r only a variation of normal.

her bleeding is abnormal o

determine whet

any change in general health. The patient must keep a record of bleeding patterns to

Note also the last normal menstrual period, age of menarche and the menopause, and

should raise the possibility of coagulation disorders.

story of bleeding

family hi

bleeding or bleeding associated with dental work, bruising, frequent epistaxis

Excessive bleeding since menarche, postpartum haemorrhage, surgery related

include bowel and urinary symptoms can indicate the presence of large fibroid

symptoms

anatomical causes, while pressur

usually suggest

or postcoital bleeding

ntermenstrual bleeding

. I

and the influence on the quality of life

amount of episodes

Note the amount of menstrual flow, the length of menstrual cycle, the length and

iated symptoms

assoc

relation to sexual intercourse and

smell,

, duration, color,

and clots indicate significant loss

(flooding

Present: amount

Past

Obstetric

to determine the amount and timing of the bleeding

calendar

Menstrual

al: age, wishes of the patient

Person

)

Examination

II.

s).

give a symmetrically enlarged uteru

or endometrial carcinoma (where both can

, adenomyosis

irregular enlarged uterus)

fibroids

eveal enlargement from uterine

examination may r

uterine

imanual

can be seen, discharge can indicate infection.

of the cervix

invasive lesio

polyps and

visualized;

inflammatory vulvar and vaginal lesions can be

atrophic and

: lesions, lacerations,

rigin of the bleeding as Pelvic

To see the

Pelvic:

liver, spleen, pelvi abdominal mass

Abdominal:

, reflexes

and

largement, bruising

thyroid en

pallor, endocrinopathy, coagulopathy, pregnancy, hirsutism, acne, galactorrhea,

General:

(

Investigations

III.

Systemic and local:

Investigation

Indication

-Full blood count

Histological assessment of the endometrium

Colposcopic examination

Endocervical / high vaginal swabs

Thyroid function tests

Coagulation n screening

(pelvic

valuation of the uterine cavity

-E

ultrasound, including saline infusion
sonography, and outpatient hysteroscopy).

- All women with HMB.

If history suggestive of coagulation disorder.

- Only from women with other symptoms of
thyroid disease.

intervention.

women prior to surgical

nd all

women when medical treatment has failed a

Symptomatic women ˃ 45 years old, younger

Suspicion of cervical malignancy.

history suggestive of risk of infection.

- If

-Intermenstrual or postcoital bleeding, irregular
HMB, suspected structural pathology or when
medical management has failed.

Semiobjective:

pads, do not reflect the actual blood loss

bjective methods: history of passage of clots, flooding, use of large number of

methods

50% of excessive menstruation have normal amount of blood loss by objective

Assessment of the amount of the bleeding

has failed, further investigations are needed.

women in whom medical treatment

n and in younger

tigations. In older wom

inves

45 years old, it is appropriate to implement first medical treatment without further

of pathology in a woman under

strongly suggest cyclical HMB without the presence

A full blood count is indicated in all women with HMB, if history and examination

1. Su

and adnexal mass.

pregnancy complications

fibroids, intrauterine polyps,

intramural or submucous

: can exclude pelvic masses,

(transabdominal)

1. TAS

Ultrasonography:

2.Lack of availability or experience

he apparatus

1.Cost of t

Disadvantages:

pathology in the uterine cavity.

and currently is regarded as the gold standard evaluation of

Outpatient procedure

Biopsy of the suspected areas

hyperplasia.

& diagnosis of polyps, submucous fibroid,

Excellent view of the uterine cavity

: Advantage

3. Hysteroscopy

2. Dilatation and curettage ( D&C

general anesthesia.

) an outpatient procedure, without

(Pipelle or Sharman

. Aspiration curettage

Methods:

sonographic endometrial feature

uspicious

if abnormal bleeding or

PCOS

poly cystic ovarian syndrome (

4. In

treatment.

3. In younger women if abnormal bleeding not resolved with medical

carcinoma, tamoxifen Rx)

anovulation, nulliparity, infertility, family history of colonic and endometrial

nic

2. Those with ↑risk of endometrial malignancy ( obesity, DM, HT, chro

years

1. Age more than 4

Indications:

Diagnosis of organic disease e.g. endometritis, polyp, carcinoma, TB, fibroid

provides a guide to etiology & treatment)

dding, atrophic. This

hyperplastic, proliferative, secretory, irregular ripening, she

of the type of the bleeding (Diagnosis of the type of the endometrium:

Diagnosis

Aim:

assessment

Endometrial

based on cervical smear

cted

oestrogen. Tubal and ovarian cancer can suspe

abnormal unless she is receiving

abnormalities, the presence of endometrial cells in postmenopausal women is

s), although cytology is not reliable for the diagnosis of endometrial

lesi

endocervical

rs can help screening for invasive cervical ( especially

cytological smea

in diagnosis asymptomatic intraepithelial lesions of the cervix,

Although most useful

(Pap)

Cytological examination

v. Weighing technique: need further evaluation.

. Pictorial blood loss chart

asuring menstrual blood loss.

iii.Alkaline haematin method( gold standard) for me

ii.Menstrual calendar

i.Iron deficiency anemia

•

)

Mirena

also named

IUS)

(LNG

releasing intrauterine system

Levonorgetrel

Progestogens:

Risks include thromboembolism and migrine

loss.

43% of blood

estradiol 30 mcg & levonorgetrel 150 mcg) causing reduction in

Using (ethinyl

fective in the managemnt of HMB.

considered ef

enerally

by endometrial suppression

t act

(COCP):

ombined oral contraceptive pills

II. Hormonal:

the cycle for 5 days.

Start on the first day of

menses.

acid 500 mg 3X/day during

Mefenamic

associated with gastrointestinal side effect

But they are

during menstruation and has advantage of analgesic properties.

used agent and reduces blood loss by approximately 25%. Taken

the most frequentl

leading to a reduction in menstrual blood loss. Mefenamic acid is

HMB, so they are

endometrium is a rich source of PGE2 & PGF2œ & its concentrations are greater i

the

etrial prostaglandin production as

lammatories (NSAIDs), inhibit endom

inf

steroidal anti

such as

Prostaglandin synthetase inhibitors (PSI)

Side effects are rare, include gastrointestinal symptoms.

defects.

with fibroid or coagulation

of HMB associated with IUCD,

effective in treating

ctivity is higher in HMB.

the fibrinolytic a

since

inhibiting endometrial fibrinolysis

: such as tranexamic acid, reduce blood loss by up to 50% by

Antifibrinolytics

interventions are unacceptable.

most surgical

woman is wishing to conceive, hormonal treatments and

: if a

rmonal

I. Non

B. Medical

of iron deficiency anemia

2. Treatment

calendar

1. Menstrual

A. General

most acute and chronic bleeding problems

endometrium corrects

Conversion of the endometrium from proliferative to secretory

irregular manner.

s sloughed in an

endometrium outgrows its blood supply, partially break down, and i

axis result in continuous oestrogen stimulation of the endometrium, so the

HPO

cause of bleeding is not well understood but probably result from dysfunction of the

re anovulatory, the exact

in which most of the patient a

bleeding of endometrial origin

ing, establish the diagnosis of

Exclusion of the pathological causes of abnormal bleed

Counsel the patient about treatment option.

to reassure them and make further treatment unnecessary.

sufficient

For some women, the demonstration that their blood loss is in fact ‘normal’ may be

hysterectomy to treat abnormal uterine bleeding.

result in decreased the use of

roved diagnostic technique and treatment

of AUB

Treatment

selected cases

sonography: an alternative to office hysteroscopy in

infusion

3. Saline

12 mm in follicular phase is suspicious

endometrial thickness 10

postmenopausal with endometrial thickness>4 mm and in premenopausal women

n TAS. All endometrial thickness

e tha

: More informativ

(transvaginal)

2. TVS

Imp

–ho

non-

1- C

tation and curretage (D&C) is no longer use as theraputic treatment.

modalities. D

leeding had been decrease with the introduction of new managemnt

uetrine b

for treatment of abnormal

The number of hysterectomies

is retained.

the fertility

with the exception of polypectomy and myomectomy where

complete their families

surgical treatment is considered in those who

Usually

treatment:

C. Surgical

the menstrual blood lo

effective in reducing

: still under trial as being

Selective progesterone receptore modulators (SPMR)

estrinone.

Ethamsylate

Danazol

are

because of its unacceptable side effect

Drugs that are no longer use nowaday

, for that it is not use usually more the 6 months.

after stopping treatment

ontinue

and since its effect dose not

Becuase of its adverse effect on bone density

ovarian suppression leading to amenorrhoea.

and induce

axis

HPO

nregulating the

ct by dow

failed.

are

If all other option

(GnRHa)

releasing hormone analogues

Gonadotrophin

of HMB.

ffective in the treatment

so may be

They are using as contraception and since they cause amenorrhea

gestogens

Injected/depot pro

are mainly weight gain, nausea, bloating.

Side effect

X /day) for 21 days

acetate (5mg, 3

northisterone

reproductive life

extremes of

at the

HMB

anovulatory)

with irregular (

for women

sefull

toges

Oral proges

years.

It require change every 5

related side effect are much less than oral.

progestogen

. Because of its local effect so

dometrial atrophy that it cause

because of en

no bleeding

. It associeted with little or

nd alternative to surgery

contraception a

long term

reversible

with HMB and seek reliable

Is very good choice for women

, as

It a

;

-G

ss.

ila

ulsed in the outpatient setting or

: Endocervical polyp can be av

Polypectomy

anaesthesia or in the outpatient setting.

r by hysteroscopy resection under general

under general anaesthesia o

me of the

Is the destruction of the endometrium and so

Endometrial ablation

hysterectomy.

. Some may need repeating the procedure or subsequent

contraception

g term effective

should advice to have lon

undergo this procedure

Women who

nd structural causes of HMB have been excluded.

and in whom all organic a

underlying myometrium. Suitable for woman who has complete her family

b. Resection

cal: a. Roller ball

2. Electrosurgi

1. Laser

I.Hysteroscopic:

Methods:

Gas embolism

due to absorption of distension media.

Fluid overload

is used to decrease that risk.

ntibiotics

3. Infection in the form of endometritis for that prophylactic a

Bleeding

Uterine perforation

Complications of hysteroscopic methods

3. Novasure.

2. Microwave.

1. Thermachoice

hysteroscopic:

II.Non

۰۱

2. 2.

Is surgical removal of the fibroid from the uterus with

Myomectomy

hysterectomy in case of intraoperative bleeding.

woman should be counseled before the procedure about the need for

on the location and size. Complications include bleeding and infection and the

oscopically depend

y or lapar

onservation of the uterus. Removed abdominall

AE) for the treatment of fibroid usually

Uterine artery embolization

: (U

and shrinking.

results in fibroid become avascular

carried out by interventional radiologist. Blockage of both uterine artery

Hysterectomy:

investigations will be performed looking to the cause.

clinically stable then

14 days and once the patient

of bleeding usually will occur within 10

ion

then 2X daily for 2 days then 1X daily for 3 weeks.

daily for 3 days

4X /day for 4 days then 3X

30 mcg / norgestrel 0.3 mg

Ethinyl oestradiol

is:

One of them

Several regimens had been described.

Resuscitation.

Management:

Anticoagulants.

AVMs.

Prolapsed fibroid.

Coagulopathy, most commonly is von Willebrand’s disease.

be due to the following causes:

This may

Sever acute heavy menstrual bleeding:

. Laparoscopic

history of previous caesarean section.

2. Abdominal: for large uterus, endometriosis or pelvic inflammatory disease or with

. Now is the preferred rout with small uterus.

Vaginal

Routes:

less invasive surgical options had failed.

2. Family is completed

1. Failure of medical treatment

Indications:

)

Cessat

………………………………………………………………………………………..

Postmenopausal bleeding (PMB)

Learning objectives: By the end of this lecture, you need to:

1-  Define PMB.
2-  Explain why it does occur.
3-  Discuss the causes behind PMB.
4-  List the commonest health problems which contribute for this problem.
5-  Analyze the investigations for this presentation.
6-  Summarized the treatment options.

Definition

: is bleeding from the genital tract occurring after the menopause.

Its  more  critical  than  premenopausal  bleeding.  Any  bleeding  after  1  year  of
menopause  or  menstruation  that  continue  after  the  age  of  55  years  should  be
investigated.

Pathophysiology:

• 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.

■  Benign  conditions  is  most  frequent  causes  of  PMB  as  the  majority  will  have
atrophic  vaginitis  whereby  the  vaginal  epithelium  will  thins  and  breaks  down  in
response  to  low  oestrogen    level  which  is  easily  treated  with  topical  estrogen.  But
endometrial  cancer  is  the  most  serious  potential  underlying  cause  may  be
responsible  to  10%  of  cases  and  even  more  in  developing  countries.  The
commonest cause in other countries is usually the use of hormonal replacement
therapy,  otherwise  in  developing  countries  and  in  Iraq  malignant  disease  is  an
important cause.

Clinical features:

- If the women are not taking Hormone replacement therapy (HRT), then any

bleeding is abnormal.

- In women on combined cyclical HRT, bleeding in the progesterone free period

is normal.

- Unscheduled bleeding refers to bleeding at other times or abnormal in amount,

this should be investigated as abnormal bleeding.

Causes:

Drugs



Tamoxifen: is associated with a two- to threefold increased risk of

endometrial cancer in postmenopausal women. TVUS of patients on this
therapy typically shows an increased endometrial thickness.



HRT: The occurrence of uterine bleeding or spotting after the initiation of

HRT is not unusual. More than half of HRT users will have some spotting or
bleeding at the beginning of therapy.

- Sequential (or cyclical) combined regimens cause scheduled bleeding

in  most  users.  Continuous  combined  regimens  are  associated  with  a
reduced  relative  risk  of  endometrial  cancer  but  may  cause
unpredictable spotting or bleeding during initial use.



Anticoagulants: Overuse of anticoagulant medications such as aspirin,

heparin and warfarin- which are taken with greater frequency by patients in
this age group-may contribute to postmenopausal bleeding.

Malignant neoplasms:

of the vulva, vagina, cervix, uterine body, fallopian

tubes.

Benign neoplasms

of the vulva, vagina, cervix, uterine body, fallopian tubes.

Ovarian tumours

: Oestrogen producing tumours

Infections

- Vaginitis – Trichomonas, Candida, senile.
- Endometritis – tuberculous, senile

Dysfunctional uterine haemorrhage

(Bleeeding of endometrial origin).

Injuries

-  Direct trauma
-  Decubital ulceration
-  Foreign bodies such supporting pessaries
-  Postradiation ulceration

Disease of the blood and the capillaries

: Abnormalities of the hematologic

system also must be considered as a possible cause of PMB. On rare
occasions, AUB will be the first sign of leukemia or a blood dyscrasia.

Haemorrhage from other structures

-  Urethral caruncle
-  Papilloma and carcinoma of the bladder
-  Haemorrhoids and fissure in ano
-  Carcinoma of the rectum

10-

No cause could be found

Differential diagnosis

-  Endometrial carcinoma.
-  Endometrial hyperplasia.
-  Endometrial polyp.
-  Cervical carcinoma.
-  Atrophic vaginitis.

Investigation:

1 -

Thorough history and examination

: PMB or discharge needs immediate

investigation even though there is only one episode.
2-

Blood test

to exclude blood disorders.

Cervical smear and possibly biopsy

if any pathology detected.

TVUS

( transvaginal ultrasonoraphy): Is a non invasive . It should be done for

all women with postmenopausal bleeding. Transvaginal ultrasound has a good

correlation  with  pathologic  endometrial  findings.  Using  an  endometrial  thickness  of
(4)  mm  as  upper  normal  level  (or  5  mm  if  she  is  on  HRT).  If  that  is  revealed  thick
endometrium, then other tests for endometrial assessment are indicated as:
5-

Endometrial biopsy with or without hysteroscopy

Dilation and curettage (D&C)

may be necessary for women with high risk of

endometrial carcinoma.
7-

Sonohysterography

: The introduction of intrauterine fluid (saline-infusion

sonography) during transvaginal ultrasound is one of the most significant advances in
ultrasonography.
Uterine  fibroids  and  adenomyomas  generally  are  apparent  on  ultrasound.  Uterine
polyps  may  appear  as  a  thickened  endometrial  stripe,  but  these  and  submucous
myomas  can  be  clearly  identified  as  filling  defects  when  a  sonohysterograyph  is
performed
8-

Hysteroscopy

Hysteroscopic visualization has several advantages:

  immediate out patient evaluation,
  visualization of the endometrium and endocervix,
  the ability to detect minute focal endometrial pathology and to perform

directed endometrial biopsies

Treatment:

1-If there is a cause then treating the cause.
2-When no cause in the genital tract and the haemorrhage is repeated its origin from
another  site  has  to  be  excluded  so  full  examination  of  the  urinary  system  and  the
lower bowel, including cystoscopy and sigmoidoscopy.
3-  If  bleeding  persistent  or  recurrent  with  negative  investigation  so  laparotomy  is
needed with hysterectomy which may detect an early carcinoma of the uterus, of the
tube or the ovary.
4- Hypoestrogenic atrophic changes can be treated by HRT.

Always remember:
 Endometrial carcinoma is one of the most important consideration in post

menopausal bleeding.

 Atrophy is the most common cause of post menopausal bleeding.
 Initial evaluation should include cervical cytology, transvaginal ultrasound

and / or endometrial sampling.

 Findings should be further evaluated with saline sonography or hysteroscopy.

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