Postmenopausal bleeding is any vaginal bleeding that occurs in a postmenopausal woman. A woman is said to have attained menopause when she ceases to bleed for 12 months continuously. The age of menopause is variable, but for most women, it ranges around 50 years in the Indian population.
Dr B Ramesh, Chief Obstetrician and Gynaecological Laparoscopic Surgeon, and Founder and Medical director, Altius Hospitals,explains why bleeding after menopause is a concern.
Why is postmenopausal bleeding a sign for further evaluation?
Since it is a cardinal sign of endometrial carcinoma, all postmenopausal patients with unanticipated bleeding should be evaluated. However, more commonly, the cause of bleeding in such patients results from a benign condition such as endometrial polyps or atrophy. The etiologies and evaluation of postmenopausal patients with uterine bleeding and patients near the end of perimenopausal transition with abnormal uterine bleeding is of utmost importance.
The most common is atrophy of these women's endometrium or vagina. Still, polyps and hyperplasia of endometrium, upper genital tract carcinomas like fallopian tube cancers and cervical cancers, and women who are on post-hormonal therapy, women who are on tamoxifen for breast carcinoma can experience postmenopausal bleeding. The incidence of endometrial carcinoma is 10% of the people who present to us with postmenopausal bleeding.
The risk factors for endometrial carcinoma are increasing age, unopposed estrogen therapy, tamoxifen therapy, early menarche, late menopause, nulliparity i.e women who do not have children, polycystic ovarian syndrome, obesity, diabetes mellitus or if there is a familial history of endometrial carcinoma in people who have Lynch syndrome, Cowden syndrome and so it is highly essential for us to elaborate if there are any women in the family like mother, grandmother, aunt or sisters who are suffering from endometrial, ovarian, breast, or colon cancer, which will aid us in detecting abnormality or cancer in its early stage.
What is the approach to a patient with postmenopausal bleeding?
Patient history gives us very crucial information such as when the bleeding started, preceded by factors, such as trauma or the nature of the bleeding, the duration and the quantity, if there are any other associated symptoms such as pain, fever, or any bladder or bowel dysfunction, or if the lady is on any medications. Thus, patient history is significant. Any positive history elicited from the patient will aid in further evaluation of the disease.
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Once the history is obtained, the evaluation of endometrium begins. This can either be done by transvaginal ultrasound or by taking an endometrial biopsy. During the sitting, evaluation of the cervix is also necessary and all these patients with postmenopausal bleeding definitely need an evaluation to rule out cervical cancer. However, it is difficult to distinguish between uterine and endocervical bleeding but if any visible lesions are present in the cervix, they can be biopsied and even a cervical cytology can be performed. When we talk about endometrial biopsy, it is definitely preferred over just an ultrasound because it results in tissue diagnosis and has high sensitivity.
When do patients require endometrial biopsy?
On an ultrasound examination, if the endometrial lining is less than 4 millimeters and it is of homogeneous endometrium, then it is unlikely that it is endometrial carcinoma. So, these patients can be kept on follow up but if the endometrial lining is more than 4 millimeters and the endometrium does not appear homogeneous or there is a focal lesion in the endometrium then definitely a biopsy is required in these patients.
There are 3 ways where in this endometrial biopsy can be performed:
Office Biopsy: It is pipelle biopsy, it can be done on an outpatient basis. It is usually performed under local anesthesia and it hardly takes 5 minutes for us to obtain the sample. But, the disadvantage of office biopsy is that it is a blind procedure. It may yield very scanty specimens and may not be reflective of the entire underline pathology. Sometimes, only a sample of proportion of the endometrium is obtained. So, it is difficult to obtain a site specific biopsy using this biopsy
Dilatation and Curettage: DNC- D & C (dilatation and curettage) This requires a little more sedation because it is usually painful. It is also an option for people who cannot undergo office endometrial biopsy due to anxiety or cervical stenosis, previous c-sections. And if the office biopsy is not diagnostic and there was insufficient tissue obtained then dilatation and curettage may fetch us better results.
What is the role of Hysteroscopy and biopsy in patients?
Hysteroscopy is always superior to DNC and Pipelle biopsy as the endometrial cavity is visualized in this procedure. The American society of gynecological oncology also says that hysteroscopy is the way to go for postmenopausal bleeding. Especially on ultrasound if the endometrial lining is thick or there is any focal heterogeneity noted. Hysteroscopy requires a general anesthesia and it is also a day procedure.
Women who are known to have Lynch syndrome, Cowden syndrome in their families should undergo prophylactic hysterectomy along with oophorectomy once they have completed their family. And according to guidelines, 35 years is the start of the screening procedures for high risk women.
What is the best treatment approach to Postmenopausal Bleeding?
Treatment approach to Postmenopausal bleeding is disease specific. If the lady is suffering from atrophic vaginitis or endometritis, then hormonal therapy will aid in treating it. If we find that there is a polyp or any benign pathology during the scan, then the benign pathology like the polyp or the fibroid can be removed.
Ultrasound also aids in diagnosing if there is any ovarian pathology or tumor which is causing this bleeding and that has to be dealt with separately. But if stage 1 endometrial carcinoma has been diagnosed in the lady then hysterectomy along with removal of bilateral fallopian tubes and ovary is the mainstay approach.
Share a few tips for early detection of endometrial carcinoma
It is beneficial to educate women and urge them to seek professional help with the first episode of bleeding once they have attained menopause. People who have the risk factors or have any family history, they should always undergo a routine checkup so that we can detect the disease in its most initial stage and be able to treat it.