Model Answer
0 min readIntroduction
Post-menopausal bleeding (PMB) is defined as any vaginal bleeding occurring six months or more after the cessation of menstruation. While often benign, PMB is a significant clinical presentation as it can be a symptom of endometrial cancer, particularly in developed countries. The incidence of PMB varies, but it affects approximately 5-10% of postmenopausal women. Prompt and thorough investigation is crucial to exclude malignancy and provide appropriate management. This answer will detail the common causes of PMB and outline a systematic approach to its investigation.
Causes of Post-Menopausal Bleeding
The causes of PMB can be broadly categorized as follows:
1. Endometrial Causes (Approximately 80-90% of cases)
- Endometrial Hyperplasia: Proliferation of the endometrial glands, often due to unopposed estrogen.
- Endometrial Polyps: Benign growths in the endometrium.
- Endometrial Cancer: Malignant transformation of the endometrial cells. Risk factors include obesity, diabetes, hypertension, and late menopause.
2. Exogenous Estrogen
- Hormone Replacement Therapy (HRT): Unopposed estrogen can cause endometrial stimulation and bleeding.
- Selective Estrogen Receptor Modulators (SERMs): Drugs like tamoxifen, used in breast cancer treatment, can have estrogenic effects on the endometrium.
3. Atrophic Vaginitis & Endometritis
- Estrogen Deficiency: Reduced estrogen levels lead to thinning and dryness of the vaginal and endometrial lining, making them prone to irritation and bleeding.
4. Malignant Causes (Other than Endometrial Cancer)
- Cervical Cancer: Bleeding can occur due to lesions on the cervix.
- Ovarian Cancer: Rarely, ovarian cancer can present with vaginal bleeding.
- Uterine Sarcoma: A rare type of uterine cancer.
5. Other Causes
- Coagulopathy: Bleeding disorders can cause PMB.
- Vaginal or Vulvar Lesions: Inflammation, ulcers, or tumors.
- Iatrogenic: Trauma from procedures like endometrial biopsy.
Investigation of Post-Menopausal Bleeding
A systematic approach to investigation is essential. The following steps are generally followed:
1. History and Physical Examination
- Detailed History: Duration, frequency, and amount of bleeding; associated symptoms (pain, weight loss); medical history (HRT use, cancer history, comorbidities); family history of cancer.
- Physical Examination: General physical examination, abdominal examination, and speculum examination to assess the vagina and cervix.
2. Non-Invasive Investigations
- Complete Blood Count (CBC): To assess for anemia.
- Coagulation Profile: To rule out bleeding disorders.
- Urine Analysis: To rule out urinary tract infection.
- Transvaginal Ultrasound (TVUS): The initial imaging modality of choice. It assesses endometrial thickness, presence of polyps or fibroids, and ovarian morphology. An endometrial thickness >4mm warrants further investigation.
- Saline Infusion Sonohysterography (SIS): Ultrasound performed after instilling saline into the uterine cavity. Improves visualization of the endometrium and can detect polyps or submucosal fibroids.
3. Invasive Investigations
- Endometrial Biopsy: The gold standard for diagnosing endometrial cancer and hyperplasia. Can be performed in the office (pipelle biopsy) or as a dilatation and curettage (D&C).
- Hysteroscopy: Direct visualization of the uterine cavity using a hysteroscope. Allows for targeted biopsy and removal of polyps.
- Dilation and Curettage (D&C): A surgical procedure to scrape the uterine lining. Used when biopsy is inadequate or hysteroscopy is not feasible.
4. Further Investigations (Based on Findings)
- Cervical Cytology (Pap Smear): If cervical cancer is suspected.
- CT Scan/MRI: To assess for spread of cancer if malignancy is confirmed.
| Investigation | Purpose | Advantages | Disadvantages |
|---|---|---|---|
| TVUS | Assess endometrial thickness & morphology | Non-invasive, readily available | Operator dependent, limited visualization |
| Endometrial Biopsy | Diagnose endometrial cancer/hyperplasia | Gold standard, relatively simple | Can be uncomfortable, sampling error |
| Hysteroscopy | Direct visualization & targeted biopsy | High accuracy, allows for polyp removal | Requires anesthesia, risk of uterine perforation |
Conclusion
Post-menopausal bleeding requires a thorough and systematic investigation to exclude malignancy, particularly endometrial cancer. The initial approach involves history, physical examination, and TVUS. Endometrial biopsy remains the gold standard for diagnosis. Management depends on the underlying cause and may range from observation to hormonal therapy or surgical intervention. Early diagnosis and appropriate management are crucial for improving outcomes in women presenting with PMB.
Answer Length
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