Postmenopausal Bleeding
Postmenopausal Bleeding: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Victoria S. Kaprielian
Postmenopausal bleeding is defined as vaginal bleeding that occurs in a woman who has had no menses for a year or more. This is a common outpatient problem, estimated to account for approximately 5% of gynecologic office visits.
Approach
Any vaginal bleeding in a postmenopausal woman not on hormone replacement therapy (HRT) requires a diagnosis, as malignant causes are found in 10% to 20% of cases. Endometrial cancer is the primary concern; other malignancy may occasionally be implicated. Nonmalignant causes include endometrial atrophy [up to 82% of cases (1)], endometrial hyperplasia or polyps, cervical polyps, infections, and lacerations. Women on cyclic HRT are expected to have uterine bleeding; bleeding at unexpected times or in excessive amounts requires investigation.
History
A. Pattern of bleeding. Although the amount of bleeding is not helpful in identifying malignancy, it should be assessed to determine the likelihood of significant anemia or hypovolemia that may require intervention. Timing of bleeding may suggest its cause.
1. Specific relationship to medication courses or cycles suggests drug-induced bleeding.
2. Postcoital bleeding suggests an atrophic cause or cervical polyp.
3. Association with bowel movements or urination suggests a nongenital source.
B. Current medications. Any hormonal therapy, including estrogen, progesterone, tamoxifen, thyroid replacement, or corticosteroids, should be quantified and recorded.
1. Acyclic bleeding is common in the first 3 to 4 months on continuous estrogen–progestin therapy, and usually does not indicate pathology. Bleeding that is excessive, persists after months of therapy, or occurs after amenorrhea has been established on these regimens should be evaluated.
2. The rate of endometrial cancer in women on tamoxifen or unopposed estrogen is six to seven times the rate for untreated women. The frequency of endometrial polyps is also increased.
3. Exogenous corticosteroids and incorrect dosage of thyroid replacement can lead to menstrual irregularities and postmenopausal bleeding.
C. Past medical history. Nulliparity, early menarche, late menopause, and history of chronic anovulation are risk factors for endometrial hyperplasia and carcinoma. Obesity, hypertension, diabetes, and liver disease are commonly associated with estrogen excess, and can also increase risk (1). Past use of oral contraceptives is associated with decreased risk.
D. Family history. A strong family history of endometrial or colon cancer is a risk factor for endometrial cancer.
Physical examination
A. Vital signs. Blood pressure and pulse can indicate the degree and acuity of blood loss; orthostatic changes can be evidence of significant volume depletion. Fever suggests infection as a potential cause (Chapter 2.6).
B. Abdomen. Tenderness or guarding suggests an infectious or inflammatory cause. Palpation for suprapubic masses is necessary as part of the evaluation for malignant causes.
C. Pelvis. Examine external genitalia, vagina, and cervix for lesions or lacerations that could be the source of bleeding. The uterus and ovaries must be palpated to assess for enlargement, masses, and tenderness.
D. Rectum. Rectal examination and anoscopy may be warranted to rule out hemorrhoids or other intestinal source of bleeding (Chapter 9.11).
Testing
A. Office laboratory testing. Urinalysis, stool guaiac testing, or both can be useful to look for nongenital sources of blood. A complete blood count may be helpful in assessing the degree of blood loss and likelihood of infection. Testing for gonorrhea and chlamydia may be warranted when tenderness or fever is present.
B. Pap smear. Many sources recommend a pap smear as part of the evaluation, although its diagnostic yield in these cases is low. Cervical lesions or friability raise the possibility of a cervical bleeding source. Endometrial cells found on the pap smear of a postmenopausal woman not on HRT warrants further evaluation of the endometrium.
C. Biopsy
1. Visible lesions of the vulva, vagina, or cervix should be sent for biopsy.
2. In the absence of a clear nonuterine source of bleeding, endometrial biopsy is usually recommended. This office test can cost-effectively identify endometrial hyperplasia and carcinoma, with a sensitivity of 85% to 95% (3), and it is lower in cost and risk than other procedures (2).
3. Traditional wisdom required dilation and curettage (D&C) for diagnosis if endometrial biopsy was negative. Recent evidence indicates this is unlikely to be of benefit (despite higher risk and cost), except in cases where other procedures are not possible (2–5).
4. If bleeding continues after normal biopsy, consider repeat biopsy or assessment by another method (5).
D. Diagnostic imaging
1. Palpable adnexal abnormalities should be evaluated by ultrasound or other imaging as appropriate.
2. Transvaginal ultrasound (TVUS) is gaining popularity as an alternative or adjunct to endometrial biopsy. A clearly identifiable endometrial stripe less than 4 or 5 mm in thickness is highly unlikely to contain hyperplasia or carcinoma, and biopsy may not be necessary (2,4). Fluid in the endometrial cavity has been associated with carcinoma, and its presence warrants further investigation (5). TVUS should not be used in place of biopsy in women on tamoxifen, as the drug is known to cause misleading ultrasound findings (3,5).
3. Hysteroscopy is becoming the “gold standard” against which other methods of endometrial assessment are compared (4,5). Flexible hysteroscopy allows direct visualization of the endometrium in the office setting, and can be used for directed biopsy and removal of small polyps. Rigid hysteroscopy allows greater intervention, but requires greater anesthesia.
4. Sonohysterography (ultrasound evaluation after instillation of fluid into the endometrial cavity) appears to offer promise as another alternative that provides additional information on the uterine architecture (3,5). This is the subject of ongoing study, especially in comparison with hysteroscopy, which provides similar information and may allow simultaneous biopsy of identified lesions.
Diagnostic assessment
Initial clinical evaluation may identify a nonuterine source. Postcoital spotting in conjunction with vaginal atrophy or cervical friability suggests cervical or vaginal mucosal bleeding. Gross hematuria or visibly bleeding hemorrhoids suggest that the bleeding source is not genital. If no other source is identified, however, the key to diagnosis is imaging and tissue sampling of the endometrium. A thin endometrial stripe in a woman in a low-risk category suggests endometrial atrophy. Findings on biopsy can include atrophy, proliferative changes, various degrees of hyperplasia (simple, complex, and atypical, in increasing order of risk), or carcinoma. If neither biopsy nor TVUS provides sufficient information, hysteroscopy is the recommended next step. D&C should be reserved for cases in which other methods are unsuccessful or unavailable.
References
1. Shelly MS. Endometrial biopsy. Am Fam Physician 1997;55(5):1731–1736.
2. Feldman S, Berkowitz RS, Tosteson ANA. Cost-effectiveness of strategies to evaluate post-menopausal bleeding. Obstet Gynecol 1993;81(6):968–975.
3. O’Connell LP, Fries MH, Zeringue E, Brehm W. Triage of abnormal postmenopausal bleeding: a comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopy. Am J Obstet Gynecol 1998;178(5):956–961.
4. Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in evaluation of patients with abnormal uterine bleeding: clinical implications. Am J Obstet Gynecol 1995;172(2):547–552.
5. Good AE. Diagnostic options for assessment of postmenopausal bleeding. Mayo Clin Proc 1997;72:345–349.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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