Case 11: Postmenopausal bleeding

 

Case 11: Postmenopausal bleeding

CASE 11: POSTMENOPAUSAL BLEEDING

History

A 59-year-old woman awoke with blood on her nightdress, which was bright red but not

heavy. There were no clots of blood and there was no associated pain. The bleeding has

recurred twice since in similar amounts.

Her last period was at the age of 49 years and she has had no other intervening bleeding

episodes. She suffered hot flushes and night sweats around the time of her menopause,

which have now stopped. She is sexually active but has noticed vaginal dryness on intercourse recently.

She has always had normal cervical smears, the last one being 7 months ago. She had two

children by spontaneous vaginal delivery and had a laparoscopic sterilization aged 34 years.

She has never used hormone-replacement therapy (HRT). She takes atenolol for hypertension

and omeprazole for epigastric pain.

Examination

She is slightly overweight. Abdominal examination is normal. The vulva and vagina appear

thin and atrophic and the cervix is normal. The uterus is small and anteverted and with no

palpable adnexal masses.

An outpatient endometrial biopsy is taken at the time of examination and sent for histological examination.

INVESTIGATIONS

Transvaginal ultrasound scan is shown in Fig. 11.1.

Endometrial biopsy report: the specimen shows atrophic endometrium with no evidence

of inflammation, hyperplasia or malignancy.

Questions

• What is the likely diagnosis?

• How would you manage this patient?

Figure 11.1 Transvaginal ultrasound

scan showing a midsagittal view

of the uterus and endometrial

‘stripe’. The endometrial thickness is

measured to be 2.8 mm.100 Cases in Obstetrics and Gynaecology

28

ANSWER 11

Postmenopausal bleeding is considered to be caused by endometrial cancer until proven

otherwise. However only 10 per cent of women with postmenopausal bleeding are diagnosed

with endometrial cancer.

! Causes of postmenopausal bleeding

• Endometrial cancer

• Endometrial/endocervical polyp

• Endometrial hyperplasia

• Atrophic vaginitis

• Iatrogenic (anticoagulants, intrauterine device, hormone-replacement therapy)

• Infective (vaginal candidiasis)

In this case the endometrium is <3 mm on ultrasound, which effectively excludes an endometrial malignancy or polyp. The normal endometrial biopsy report confirms the absence

of endometrial pathology. The smear history is normal, and the cervix appears normal,

excluding cervical cancer. She is not taking any medication that may predispose to abnormal bleeding.

The diagnosis of atrophic vaginitis can therefore be made by exclusion of serious causes, and

is backed up by the history of vaginal dryness at sexual intercourse and the atrophic vulva

and vagina noted on examination.

Management

Treatment is hormonal with a course of topical oestrogen given daily for 3 weeks and then

twice weekly for maintenance, for an initial period of 2–3 months. An alternative solution is

to give a combined form of systemic HRT to protect the endometrium.

Some women are reluctant to use HRT because of the associated risks, and therefore advice

should be given about vaginal lubricants which decrease discomfort but have no reparative

value. If bleeding recurs after treatment or the diagnosis is in doubt, then further investigation with hysteroscopy and biopsy, ideally as an outpatient procedure is needed.

KEY POINTS

• Women with postmenopausal bleeding (PMB) should be considered to have

endometrial cancer until proven otherwise.

• Endometrial thickness, endometrial biopsy and hysteroscopy are used to investigate PMB.

• Endometrial thickness less than 4 mm in a woman with postmenopausal bleeding

reduces the probability of carcinoma to less than 3 per cent (although individual

protocols may use different cutoff levels).

• Atrophic vaginitis can be treated with courses of topical oestrogens