Dr. Gayatri Deshpande

Dr. Gayatri Deshpande
Sr. Consultant Gynaecology
Nanavati Super Speciality
Hospital, Mumbai

Reading the Warning Signs

What, when and why of postmenopausal bleeding

Menopause is defined by WHO as permanent cessation of menstruation resulting from the loss of ovarian follicular activity. From clinician’s perspective, any occurrence of vaginal bleeding after 12 months of amenorrhea (cessation of menstrual cycle) should be considered as postmenopausal bleeding. This condition is prevalent in 3% to 5% of postmenopausal women and definitely warrants investigations.

The cause of these symptoms may be benign lesions like Vaginal Atrophy, Endometrial Polyps, Endometrial Hyperplasia, Submucous Fibroid etc. However, primary aim in investigation is to rule out Endometrial Cancer and Cervical Cancer. There are other conditions like unopposed estrogen therapy (without progesterone) or prolonged tamoxifen administration in women suffering from breast cancer.

The risk of endometrial carcinoma with PMB rises with age from 1% at the age of 50 years to 25% at the age of 80 years. The high risk factors are: Age of menarche < 10 years, late Menopause > 55 years, Nulliparity, Obesity, co-morbidities like Diabetes Mellitus, Liver disease and Hypertension. Use of unopposed estrogen and addition of > 2 risk factors increases the risk.

The examination must rule out local causes like Atrophic Vaginitis, Vulvar Lesions, Cervical Lesions as well as Endo-cervical Polyp. A cervical smear (PAP smear) must be done to rule out cervical precancer lesions. The incidence of CIN III (pre-cancerous lesion of cervix) is 11 per 1 lakh in well screened women but 59 per 1 lakh in those who are not regularly screened (PAP smear).

Important modality of investigation is trans-vaginal ultrasound. The endometrial thickness more than 4 mm is suspicious and warrants biopsy. Those who undergo tamoxifen therapy, the thickness more than 9mm should be the cut off. Hystero-sonography (Transvaginal Ultra sound with instillation of normal saline) helps to delineate lesions line Endometrial Polyps and Submucous Fibroid. MRI helps to identify size and site of primary Tumour (Endometrial), any evidence of myometrial invasion and presence of lymph node metastases. To confirm the diagnosis, the retrieval of endometrium by Hysteroscopically guided Endometrial Biopsy is the Gold standard. A blind D & C is known to miss more than 40% of endometrial tissue. Hysteroscopy offers an advantage of diagnostic as well as therapeutic benefit to the patient.

Endometrial Hyperplasia is an estrogen dependent condition. It can be a simple Endometrial Hyperplasia – 1 to 5% progression to cancer and complex Endometrial Hyperplasia – 5 to 25%. Management of simple Hyperplasia could be administration of long term progestogens and strict monitoring by ultrasound. Levonorgestrel IUCD (Mirena) is also proved to be effective in converting the Hyperplastic Endometrium into Atrophic type. However atypical Hyperplasia warrants Hysterectomy.