Postmenopausal bleeding

Postmenopausal bleeding: Excerpt from Professional Guide to Diseases (Eighth Edition)

Postmenopausal bleeding is defined as bleeding from the reproductive tract that occurs 1 year or more after cessation of menses. Sites of bleeding include the vulva, vagina, cervix, and endometrium. The prognosis varies with the cause.

Causes

Postmenopausal bleeding may result from:

❑ exogenous estrogen, when administration is excessive or prolonged or when small amounts are given in the presence of a hypersensitive endometrium

❑ endogenous estrogen production, especially when levels are high, as in persons with estrogen-producing ovarian tumor; however, in some persons, even a slight fluctuation in estrogen levels may cause bleeding

❑ atrophic endometrium due to low estrogen levels

❑ atrophic vaginitis, usually triggered by trauma during coitus in the absence of estrogen production

❑ aging, which increases vascular vulnerability by thinning epithelial surfaces, increasing vascular fragility, producing degenerative tissue changes, and decreasing resistance to infections

❑ cervical or endometrial cancer (more common after age 60)

❑ adenomatous hyperplasia or atypical adenomatous hyperplasia (usually considered a premalignant lesion).

Signs and symptoms

Vaginal bleeding, the primary symptom, ranges from spotting to outright hemorrhage; its duration also varies. Other symptoms depend on the cause. Excessive estrogen stimulation, for example, may also produce copious cervical mucus; estrogen deficiency may cause vaginal mucosa to atrophy.

Diagnosis

Diagnostic evaluation of the patient with postmenopausal bleeding should include physical examination (especially pelvic examination), a detailed history, standard laboratory tests (such as complete blood count), and cytologic examination of smears from the cervix and the endocervical canal. An endometrial biopsy or dilatation and curettage (D & C) with hysteroscopy reveals pathologic findings in the endometrium.

Diagnosis must rule out underlying degenerative or systemic disease. For instance, evidence of elevated levels of endogenous estrogen may suggest an ovarian tumor. Before testing for estrogen levels, the patient must stop all sources of exogenous estrogen intake — including face and body creams that contain estrogen — to rule out excessive exogenous estrogen as a cause.

Treatment

Emergency treatment to control massive hemorrhage is rarely necessary, except in advanced cancer. Treatment may include D & C to relieve bleeding. Other therapy varies according to the underlying cause. Estrogen creams and suppositories are usually effective in correcting estrogen deficiency because they’re rapidly absorbed. Hysterectomy is indicated for repeated episodes of postmenopausal bleeding from the endometrial cavity. Such bleeding may indicate endometrial cancer.

Special considerations

Obtain a detailed patient history to rule out excessive exogenous estrogen as a cause of bleeding. Ask the patient about use of cosmetics (especially face and body creams), drugs, and other products that may contain estrogen. Discuss the risks and benefits of estrogen replacement therapy with her.

❑ Provide emotional support. The patient will probably be afraid that the bleeding indicates cancer.

❑ To prevent disorders that cause postmenopausal bleeding, stress the fact that periodic gynecologic examinations are as important after menopause as they were before.

Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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