Postmenopausal uterine bleeding

Abstract

The incidence of uterine or adnexal malignancies in the 211 patients with postmenopausal uterine bleeding was 27.5 per cent (58 patients). It is low because our current practice of hospitalizing most patients with postmenopausal uterine bleeding has increased the total number of patients to a greater extent than it has the number of patients with cancer.Benign lesions were the cause of, or were involved in the production of the bleeding in 72 (34.1 per cent) of the 211 patients.The cause of the bleeding could not be demonstrated in 81 (38.4 per cent) of the 211 patients. This is a greater incidence than recorded in most reports because we exclude as causes such pathologic findings as chronic cervicitis (diagnosed histologically), adenomyosis, atrophic endometrium, and some fibroids.A single episode of spotting for 2 days, 2 or 3 months before the patient is examined, may indicate the presence of cancer. Postmenopausal patients with cancer may have no bleeding at all for 3 to 6 months between episodes or after a single episode of uterine bleeding. This occurred in 9 of the 58 patients with cancer reported here. The longest period without flow was 6 months. This happened in 2 of the 9 patients. The conclusion drawn is that even though the bleeding occurs several months prior to the time the patient reports to her physician, it must be considered to be indicative of cancer until it is proved otherwise.The quantity, duration, or character of the bleeding neither indicates accurately the extent of the cancer nor provides a means of distinguishing malignant from benign lesions.Curettage is not infallible although it is so considered by many clinicians. In 3 of the 52 patients with uterine cancer curettage failed to provide the diagnosis and caused a delay of 6, 14, and 17 months, respectively, in the recognition of the endometrial carcinomas.In the management of postmenopausal uterine bleeding curettage should always be performed. It is considered adequate therapy in many instances. In our study 97 (63.4 per cent) of the 153 patients in whom the bleeding was from nonmalignant cause were so treated. This procedure should always be accompanied by curettage of the endocervix and multiple cervical biopsies. It is important that such patients have follow-up examinations, since postmenopausal patients with uterine cancer may have no bleeding for periods of 3 to 6 months, and since curettage and cytosmears are not completely reliable.Definitive procedures (hysterectomy or radiation) are carried out at the time of the curettage whenever feasible. This is desired because the incidence of cancer is high in patients with postmenopausal bleeding, and because it is known that the diagnostic procedures are subject to error. Of the 153 patients with bleeding from benign causes, 56 (36.6 per cent) were treated definitively. Fifty of these were so treated at the time of the curettage. Often there are coexisting lesions that require surgical management, such as vaginal relaxation, which provides the opportunity to extend the procedure to include removal of the pelvic organs. In other instances, bleeding alone is an adequate indication for consummation of definitive measures. Of these 56 patients, definitive treatment was carried out in 12 for the indication of bleeding only.We prefer surgical procedures to radiation in the treatment of patients with postmenopausal uterine bleeding from nonmalignant causes. Radiation is reserved for the treatment of malignancies. It is used in benign conditions only when there are contraindications to surgical procedures. Our preference of surgical procedures is vaginal hysterectomy but in the past we have not always removed the tubes and ovaries if they were atrophic and free of tumor and if the procedure was unusually difficult. We are now convinced that they must be removed when a hysterectomy is performed in a patient with postmenopausal uterine bleeding. If this cannot be accomplished readily vaginally, either a combined vaginal and abdominal procedure should be performed or the abdominal approach should be selected initially.If bleeding continues or recurs after a diagnostic curettage is performed, a second curettement is indicated. At the same time, if the bleeding is determined to be from a benign cause, definitive treatment is given. This is done unless there is some contraindication.Curettage, repeated at intervals, does not constitute the best management of continued or recurrent postmenopausal uterine bleeding.