Cause Of Postmenopausal Bleeding Research Articles

Sangrado uterino anormal en la postmenopausia: diagnóstico y manejo

En la mujer postmenopáusica la presencia de sangrado uterino anormal en forma espontánea e inesperada requiere evaluación rigurosa para determinar el origen de dicho sangrado. La causa más común de sangrado postmenopáusico es la atrofia endometrial y pólipo endometrial; sin embargo, es necesario descartar cáncer endometrial que es la causa en aproximadamente el 10 por ciento de pacientes. El estándar de oro para evaluar el endometrio es la ultrasonografía transvaginal y la biopsia endometrial, que son dos componentes claves que ayudan a llegar a un diagnóstico certero.

Abstract 3730: Feasibility of office hysteroscopy for evaluation of women with postmenopausal bleeding and association with improved pathological diagnosis

Abstract Objectives: Endometrial sampling is critical in the evaluation of women for cancers of the uterine corpus. Hysteroscopy in the operating room is associated with monetary and time expense to the patient and health care system. The purpose of this study was to compare histopathological diagnoses of endometrial biopsies obtained by office hysteroscopy (OH) versus endometrial pipelle (EP). Methods: After IRB approval, records of all women with ICD-9 diagnosis (627.1) for postmenopausal bleeding who had OH attempted in the last 5 years at a single medical institution were evaluated. Demographic data collected included age, BMI, medical comorbidities, and histopathologic diagnosis. “Inadequate tissue” for pathologic evaluation was defined as stated in the pathology report or absence of endometrial tissue on biopsy specimen. Statistical analysis was performed using chi-square and Fisher's exact testing with SPSS software. Results: 85 OHs were attempted and 50 had prior attempted EPs. 98% of OHs and 94% of EPs were successfully performed. However, adequate pathology was obtained in 93% of OHs verses 38% of EPs (p<0.01). Median age was 61 years (range 48-85) and median BMI was 32 kg/m2 (range 19-71). 5% had a BMI<25. The prevalence of diabetes mellitus, hypertension, hyperlipidemia, and cardiovascular disease were 32%, 74%, 44%, and 21% respectively. There was a significant difference in pathologic diagnoses between OH and EP (p <0.01). Six patients were diagnosed with endometrial hyperplasia, and 3 with endometrial cancers by OH that were not identified by EP. Conclusions: OH is a feasible procedure that may enhance clinicians’ ability to diagnose benign, pre-malignant and malignant causes of post-menopausal bleeding. Further research is needed to understand the association of cost and quality of life with OH versus hysteroscopy in the operating room. Table 1.Pathology findings from OH vs. EPPathologyOffice Hysteroscopy (OH)%Endometrial Pipelle Biopsy (EP)%n = 79n = 19Endometrial Cancer34%00%Endometrial Hyperplasia68%00%Benign Endometrium1924%1053%Atrophic Endometrium45%421%Benign Endometrial Polyp4759%526% Citation Format: Jacquelyn M. Shaw, Sukrant Mehta, Scott Chudnoff, Mark Levie, Mark H. Einstein, Gary L. Goldberg, Nicole S. Nevadunsky. Feasibility of office hysteroscopy for evaluation of women with postmenopausal bleeding and association with improved pathological diagnosis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3730. doi:10.1158/1538-7445.AM2015-3730

Causes of post-menopausal bleeding

Debra Holloway outlines the possible causes of post-menopausal bleeding and suggests a variety of options for treatment and management

The value of red blood cell distribution width in endometrial cancer.

Red cell distribution width (RDW) is a routinely examined parameter with the complete blood count. In recent studies, RDW levels have been associated with cardiovascular, liver and renal diseases and solid tumors. The aim of this study was to evaluate the alterations of RDW levels in benign and malignant causes of postmenopausal bleeding and to investigate the association of RDW levels with clinicopathological parameters of endometrial cancer (EC) patients. A retrospective study was made of a total of 884 females who were admitted to hospital for postmenopausal bleeding between May 2009 and December 2013. After inclusion and exclusion criteria were applied, 222 patients remained. Complete blood count data was obtained from the recorded computerized database. After pathological evaluation, the patients were divided into two groups, benign and malignant (EC). The EC group (n=113) had significantly higher RDW levels compared to the benign group (14.78±2.02 vs. 13.88±1.05; p=0.000). Grade II and above EC patients had higher levels of RDW than Grade I patients (15.2±2.3 vs. 14.1±1.00; p=0.005). Correlation analyses also revealed a negative correlation between RDW and hemoglobin levels (p=0.000), RDW and mean corpuscular volume (p=0.000), RDW and lymphocyte count (p=0.035) but a positive correlation between RDW and platelet to lymphocyte ratio (p=0.030). The results of the current study revealed the potential predicitve role of RDW in patients with postmenopausal bleeding. Significant associations were also determined between RDW and clinicopathological characteristics in EC patients.

Comment on the "Recommendations for the Diagnosis and Treatment of Endometrial Cancer-Update 2013" by G. Emons and P. Mallmann for the Uterus Commission of AGO.

Prior to starting work on the planned S3 guideline on the “Diagnosis and Treatment of Endometrial Cancer”, G. Emons and P. Mallmann, acting for the Uterus Commission of AGO, provided a summary of the current state of affairs 1. The summary, which consisted of a brief outline of the main points, was discussed in detail by the Uterine Malignancies Project Group of the Munich Tumor Center, and two points in particular prompted the following comments: 1. “Every bleeding in the postmenopausal period should be investigated histologically irrespective of ultrasound assessment of endometrial thickness.” This recommendation should be qualified. About 5 % of all gynecological consultations are for postmenopausal bleeding, and 4–11 % of all women experience some form of such bleeding. The causes of postmenopausal bleeding are listed below and include: Endometrial atrophy: 59 % Endometrial polyps: 12 % Hormonal causes: 7 % Serometra, pyometra, haematometra: 2 % Endometrial hyperplasia: 10 % Endometrial cancer: 10 % If we were to follow the recommendation cited above, around 80–90 % of all women with postmenopausal bleeding would require hysteroscopy and fractionated curettage with all the potential associated complications to investigate the cause of bleeding to diagnose a benign (in some cases such as atrophy, physiological) change. We therefore consider that the procedure recommended by the American College of Obstetricians and Gynecologists (ACOG) is more suitable, as this is based on an assessment of endometrial thickness which can usually be measured extremely well with vaginal ultrasound. The ACOG recommends only carrying out histological investigations if endometrial thickness is > 4 mm (double endometrial thickness, measured in the sagittal plane as the distance between the anterior stratum basalis to the posterior stratum basalis layer), and which can be done either by endometrial biopsy or hysteroscopy with curettage 3. This approach has a negative predictive value of 99.4–100 % and is sufficiently reliable to exclude a diagnosis of malignancy as the cause of postmenopausal bleeding; this would spare the majority of women from having to undergo an operative intervention. We therefore propose the following wording: “Every first-time bleeding in the postmenopausal years should be investigated histologically if an endometrial thickness of > 4 mm is detected with vaginal ultrasound. Repeated bleeding in the postmenopausal years should be investigated histologically irrespective of ultrasound findings.” 2. “Atypical bleeding in perimenopausal women should be investigated histologically.” But what does “atypical bleeding in perimenopausal women” mean? During perimenopause, the intervals between bleeding may be quite long without the bleeding being atypical. In most cases, constant bleeding due to hormonal imbalance during perimenopause can be remedied with hormone therapy and histological investigation is only necessary if bleeding is refractory to hormone therapy. No further treatment is required as either the menstruation cycle will spontaneously become regular again or postmenopausal amenorrhea will follow. We therefore suggest changing this recommendation as follows: “Therapy-resistent or persistent perimenopausal bleeding disorders should be investigated histologically”. If histological investigation is necessary because endometrial thickness cannot be measured or endometrial thickness exceeds the cut-off of 4 mm described above in a patient with postmenopausal bleeding or with persistent or therapy-resistant perimenopausal bleeding disorder, endometrial biopsy should be carried out (e.g. using the Pipelle®), as this could avoid the need for operative procedures. The Pipelle® had a sensitivity of 99.6 % in postmenopausal woman and 91 % in pre-/perimenopausal women for the diagnosis of endometrial cancer; its sensitivity for the detection of atypical endometrial hyperplasias was 81 % 2.

Histopathological Evaluation of Postmenopausal Bleeding

Post menopausal is generally regarded as an ominous and serious alarm of genital pathologies. The term post menopausal bleeding generally implies from the uterus and it is essentially the only of importance at the postmenopausal age. However in the practical sense the term also includes some instances of from the vagina, urethra or vulva, in which case a uterine source is held suspect until excluded. Being a symptom of varied etiologies and its strong association with malignancy, it should not be taken lightly. During the present hospital based cross sectional study, we aimed to find out the different histomorphological patterns of the endometrium and cervix, to assess the rate of different benign, premalignant and malignant conditions as a cause of postmenopausal bleeding. 250 specimens were selected. The material for the study was collected from the endometrial curettings, cervical biopsies and hysterectomy specimens sent for histopathological examination. Benign conditions were seen in 206 (82.4%) cases which included atrophic endometrium, proliferative endometrium, secretory endometrium, endometrial polyp, leiomyoma, tuberculous endometritis and simple cystic hyperplasia cases. Premalignant conditions such as hyperplasia with atypia were seen in 18 (7.2%) cases. Endometrial adenocarcinoma, cervical squamous cell carcinoma and Mixed Mullerian tumor (MMT) were the malignant condition seen in 26 (10.4%) cases.

English

BACKGROUND: Postmenopausal bleeding is frequent in gynaecology and accounts approximately 510% of postmenopausal women. About 10% of women with postmenopausal bleeding have a primary or secondary malignancy. Common malignancies among them are endometrial cancer, cervical cancer or an ovarian cancer. The incidence of malignancy in postmenopausal period remains sufficiently high so it requires immediate investigation for early diagnosis, vigilant follow up and prompt treatment. AIMS & OBJECTIVES: (1) To evaluate cause of Postmenopausal Bleeding (2) To detect early pre-cancerous lesions (atypia) & endometrial hyperplasia (3) To confirm benign nature of problem by ruling out carcinoma, so that medical treatment or conservative surgery can be offered and unnecessary radical surgery can be avoided. MATERIALS & METHODS: Study Design: Non-randomised longitudinal prospective observational study. Place of Study: Department Of Obstetrics & Gynaecology, M.K.C.G Medical College & Hospital, Berhampur, Odisha. Duration 0f Study: October 2010 –March 2012. Selection of Subjects: All patients having established menopause except those undergone hysterectomy/premature menopause (<40 year)/on Hormone Replacement Therapy/on anticoagulant /having bleeding disorder included. Clinical & histopathological details were collected & analysed using mean & standard deviation. RESULTS: Total 140 cases found during study period making the incidence of PMB to be 5.1%.Mean age of PMB was 57.12 ± 9.13 years, Mean parity was 4.2, Mean duration since menopause was 9.2 ± 5.77 years. Majority (52.86%) had malignant cause & 47.14% had benign cause. Overall most common cause found was cancer cervix(40%) followed by endometrial carcinoma (9.28%).Most common histopathology change in endometrium found was atrophic endometrium (40.74%). DISCUSSION: 1) The incidence of PMB decreases with increasing age but the frequency of malignancy increased with increased age & increased with increased interval between PMB & menopause. 2) Diabetes, obesity & hypertension are common medical illness in patients with PMB. These are risk factors for endometrial cancer. CONCLUSION: 1) Carcinoma of genital tract is one of the most important cause of PMB, so early detection of the causes can be life saving. 2) Endometrial sampling is a cost effective procedure to rule out endometrial carcinoma /detect in very early stage.

Postmenopausal bleeding

Postmenopausal bleeding (PMB) is one of the most common reasons for referral to gynaecology services. This is due to the concern of possible underlying malignancy, as approximately 10% of women with PMB will have endometrial cancer. With growing use of hormone replacement therapy there is increased uncertainty as to what constitutes unscheduled bleeding and careful history and examination is required. Although benign conditions represent the most frequent cause of PMB, all women will require urgent referral and investigation in secondary care.

Postmenopausal Bleeding due to a Cu-7 Intrauterine Device Retained for Thirty Years

A retained intrauterine device is a rare, but easily correctable, cause of postmenopausal bleeding (PMB). A 64-year-old woman presented to her gynecologist with PMB. Sonographic evaluation of the endometrium revealed the presence of a Cu-7 IUD retained for at least 30 years. Hysteroscopically assisted retrieval of the IUD resulted in complete resolution of symptoms. A retained IUD should be considered in the differential diagnosis for PMB. In addition, the authors recommend pelvic sonography as the first-line diagnostic modality for PMB to aid the diagnosis of retained IUD as well as other pathology.

Vaginal polyp: an unusual cause of postmenopausal bleeding

Postmenopausal bleeding (PMB) can be due to various causes. The commonest cause is atrophy of the vagina or the endometrium. Endometrial cancer accounts for 10% cases of PMB. We present this unusual case of fibroepithelial polyp of the vagina as a cause for PMB. Vaginal fibroepithelial polyp is a rare lesion, and although benign, it can be confused with malignant connective tissue lesions. Treatment is simple excision, and recurrence is extremely uncommon.

An unusual cause of postmenopausal bleeding

An unusual cause of postmenopausal bleeding

POST MENOPAUSAL BLEEDING

Objective: To find out the causes of postmenopausal bleeding and their correlation with medicalillness. DESIGN: Single centre, cross sectional study. Place and duration: The department of obstetrics andgynaecology, Shaikh Zayed Postgraduate Medical Institute and hospital, Lahore from 1 August 2000 to 30 June 2002.st thSubjects and methods: All the patients with post menopausal bleeding diagnosed during the study periods wereincluded, except patients after hysterectomy and premature menopause. Relative informations were filled in a Performaand informations were taken from case records. Results: Total 50 patients were included in the study. Maximumnumber of patients with postmenopausal bleeding were between 56-60 years (32%). Most of the patients were havingparity between 4-6 (48%). Majority of patients (32%) had symptom about 10 years after menopause. Hypertension,diabetes and obesity were commonly found medical illness in these patients, especially when cause is endometrialcarcinoma, ultrasound scan, Pap smear and endometrial biopsy are essential to rule out cause of post menopausalbleeding. 70% patients were having benign cause while 30% patients had malignant cause for post menopausalbleeding. Conclusion: Carcinoma of genital tract is one of the most important cause of postmenopausal bleeding, soearly detection of the cases can be life saving. Detailed medical evaluation, aid of ultrasonography, Pap smear andendometrial biopsy is required to find the cause of postmenopausal bleeding.

Detection of Benign Intracavitary Lesions in Postmenopausal Women with Abnormal Uterine Bleeding: A Prospective Comparative Study on Outpatient Hysteroscopy and Blind Biopsy

Study Objective To evaluate the specificity of blind biopsy in detecting benign intracavitary lesions as causes of postmenopausal bleeding in comparison with directed biopsy via hysteroscopy. Design Prospective trial without randomization (Canadian Task Force classification II-1). Setting University hospital. Patients Three hundred nineteen postmenopausal women with abnormal uterine bleeding. Interventions All patients underwent both blind biopsy (Novak’s curette) and directed biopsy via hysteroscopy (after at least a week). All patients with benign intracavitary lesions underwent operative hysteroscopy to enable the removal of polyps and intracavitary myomas or endometrial resection if required. All patients with pathologic reports of complex hyperplasia and atypical hyperplasia (20 patients) underwent vaginal hysterectomy with bilateral adnexectomy. All patients with histology reports of endometrial carcinoma (15 patients) underwent abdominal hysterectomy, bilateral adnexectomy, and pelvic lymphadenectomy. Histopathologic findings from endometrial specimens obtained after operative hysteroscopy or uterine specimens obtained after hysterectomy were used as a reference test to establish the prevalence of disease. Measurements and Main Results The sensitivity, specificity, accuracy, and positive and negative predictive values of blind biopsy and hysteroscopy were assessed to distinguish benign intracavitary formations such as polyps, submucous myomas, and endometrial hyperplasia in postmenopausal patients with abnormal uterine bleeding. The level of agreement was evaluated by use of the coefficient of concordance κ. Blind biopsy showed a sensitivity of 11% and a specificity of 93%, with an accuracy of 59% in detecting endometrial polyps, a sensitivity and specificity of 13% and 100%, respectively, with an accuracy of 98% for submucous myomas, and values of 25%, 92%, and 80%, respectively, in diagnosing hyperplasia. On the other hand, hysteroscopy demonstrated a sensitivity of 100% and a specificity of 97%, with an accuracy of 91% in diagnosing endometrial polyps, a sensitivity and specificity of 100% and 98%, respectively, with an accuracy of 99% for submucous myomas. The coefficient of concordance κ (95% CI) was 0.12 for blind biopsy and 0.82 for hysteroscopy, corresponding, respectively, to slight concordance and almost perfect agreement with final pathologic diagnosis. Conclusions Blind biopsy (Novak’s curette) demonstrates very low sensitivity and accuracy in the diagnosis of benign focal intracavitary lesions. Hysteroscopy is confirmed as the gold standard in the assessment of abnormal uterine bleeding in menopause, permitting the elimination of the false-negative results of blind biopsy through direct visualization of the uterine cavity and the performance of targeted biopsy in case of doubt.

Vaginal fibro-epithelial polyp as cause of postmenopausal bleeding: office hysteroscopic treatment

We report on the case of a 72-year-old woman who underwent office hysteroscopy following an episode of postmenopausal bleeding. A vaginal fibro-epithelial polyp was diagnosed and removed by means of a 5 Fr bipolar electrode inserted through the operating channel of a 5 mm continuous flow office hysteroscope.

Ultrasonographic endometrial thickness for diagnosing endometrial pathology in postmenopausal bleeding

SummaryWe conducted this retrospective analysis of our clinical data to identify the incidence of benign endometrial abnormalities, endometrial carcinoma and to find out the endometrial thickness (ET) cut-off point using trans-vaginal ultrasonography for patients with postmenopausal bleeding (PMB) referred to the Rapid Access Clinic in Northampton General Hospital. All women referred between April 2004 and April 2005 with PMB were included in this analysis. Final diagnostic outcome was classified into benign endometrial polyp, endometrial hyperplasia, endometrial carcinoma or normal (by excluding these pathologies). A total of 142 patients were included in this survey. The incidence of abnormal endometrial pathology was found to be 23.9% and 5% for endometrial carcinoma. Our results suggested that benign endometrial pathology is the most common cause of postmenopausal bleeding. Lowering the endometrial thickness cut-off point from 5 mm to 3 mm will not improve the diagnostic accuracy of endometrial carcinoma.

Transvaginal sonographic assessment of endometrial thickness and endometrial morphology in postmenopausal bleeding

The most common symptom of endometrial cancer is postmenopausal bleeding (PMB). However PMB is associated with endometrial cancer in only 10% of cases. Even if repeatedly performed no noninvasive procedure has been able to replace endometrial biopsy in finding the cause of PMB. This prospective study was conducted to investigate the diagnostic values of endometrial thickness (ET) and endometrial morphology (EM) in the management of PMB in 103 women who fulfilled the following inclusion criteria: no menstrual bleeding for at least 12 months abnormal uterine bleeding and no use of hormone or tamoxifen therapy. All patients underwent a transvaginal sonographic examination and an endometrial biopsy. (excerpt)

Clinical analysis of postmenopausal bleeding in 548 cases

目的 探讨绝经后阴道出血的病因和诊断.方法对2000年1月至2003年12月经我院妇科活检或手术后病理证实的绝经后阴道出血548例患者的临床资料进行回顾性分析.结果按病理分类:良性疾病引起的绝经后出血占70.3%,非器质性疾病占18.2%,恶性疾病占11.5%.良性疾病中以慢性宫颈炎最常见,恶性疾病以宫颈癌和子宫内膜癌为主.结论绝经后阴道出血的首位病因为良性疾病,其次是非器质性疾病,恶性疾病为第三位.绝经时间长的阴道出血,恶性肿瘤的发生率明显增高.对绝经后阴道出血应引起重视,常规行妇科检查结合必要的辅助检查可明确诊断。

Investigation of abnormal uterine bleeding in perimenopausal women by hysteroscopy and endometrial biopsy

The causes of abnormal uterine bleeding (AUB) during the perimenopausal period in women receiving hormone replacement therapy (HRT) were investigated, along with the causes of postmenopausal bleeding, the efficacy of hysteroscopy in the diagnosis of endometrial pathology was investigated. The patients studied were referred to our academic gynaecological clinic during the period 1999–2003. 145 cases that had undergone hysteroscopy and endometrial biopsy for AUB during the perimenopausal period over the last four years were reviewed retrospectively. The main group (76 patients) presented AUB while they were taking sequential or continuous HRT for menopausal symptoms and to prevent osteoporosis. The control group (69 patients) presented postmenopausal bleeding. There was an increased incidence of endometrial pathology in the group receiving HRT in comparison with the control group (52.6% vs. 40.4%), but this difference was not significant. The main findings were functional endometrium (38.1%) in the group receiving HRT and atrophic endometrium (40.6%) in the control group, respectively. These differences were statistically significant between the two groups. Diagnostic hysteroscopy was performed successfully with no serious complications and was performed without anesthesia in over 30% of the patients in both groups. The incidence rates of the structural endometrial causes of AUB in perimenopausal period are similar in women taking HRT and those presenting postmenopausal bleeding. Hysteroscopy is a safe and efficient method of investigating women with AUB during the perimenopausal period. In addition, the increasing use of outpatient hysteroscopy will simplify assessments of patients presenting with AUB during the perimenopausal period.

Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection

Postmenopausal bleeding (PMB) accounts for about 5% of all office gynaecology visits. The causes of PMB are varied. Many women with endametrial cancer present with this symptom. Although many investigations are described, the most appropriate approach is often unclear. In a patient with no obvious local cause, the emphasis should be on uterine and adnexal evaluation. Based on a literature review, the evidence favours a conservative approach if the endometrial thicknes (ET) is < 4mm, unless there are risk factors. All patients with ET ⩾̸ 4 mm should have outpatient endometrial sampling. If this is unsuccessful, then outpatient hysteroscopy with directed biopsy or inpatient hysteroscopy is favoured. The role of ancillary investigations are described.

Postmenopausal bleeding due to chronic DIC

‘Bleeding disorders’ are listed as a cause of postmenopausal bleeding even though there appear to be no reported cases. We present a case of postmenopausal bleeding, because of chronic DIC, which resulted from aortic aneurysm and was managed with replacement blood products and tranexamic acid.