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.