POST MENOPAUSAL BLEEDING (PMB)

Post menopausal bleeding is defined as bleeding after 12 months of amenorrhoea in women at the age of menopause. It will also include women who had early or premature menopause but not women who had amenorrhoea due to psychiatric reasons or while breast feeding. PMB should always be taken seriously and investigated although more than 80% of times will not be serious. 10 -13 % of women over the age of 60 get endometrial cancer. The risk factors for endometrial cancer are , older age,obesity, high blood pressure, diabetes, fibroids, never being pregnant, history of polycystic ovarian syndrome, being on hormones for breast cancer,  early start of periods and late menopause and inherited colon cancer syndrome .

The other common causes of PME are thinning of the vagina due to lack of oestrogens, thinning of the lining of the uterus, thickening of the uterine lining called the endometrial hyperplasia, collection of blood in the uterine cavity, polyps ( growth of the local tissues as these are generally are not cancerous)of the uterine cavity, cervical canal, and the cervix ,fibroids bulging in the uterine cavity, cancer of the cervix and vagina.

Pelvic inflammatory disease due to sexually transmitted infections; such as Chlamydia,  and gonorrhoea. Drugs such as HRT and hormone therapy, to prevent recurrence of breast cancer.  Some drugs used for blood thinning such as aspirin can also cause PMB. Sometimes bleeding from the bladder and rectum can be confused as PMB, or when a woman is suffering from PMB, do not ignore the bladder and the rectum.

HOW TO LOOK AFTER THESE WOMEN?

A detailed history about the pattern of bleeding should be compiled and how long it has been going on for also any history of post coital bleeding.  Any HRT or any other drugs, age of menarche and menopause, any children, bleeding disorders or any cancers, personally or in the family.

After the initial history taking, the clinician should discuss with the patient the causes of these problems, the route that they will take to come to a diagnosis. After the initial weight, blood pressure and general examination, a pelvic examination is then done. An explanation should then be given to the woman about what this examination covers i.e. looking at the condition of the vaginal and cervical tissues. Cervical smear can be done. The sizes of the uterus are assessed and look for any pelvic masses.  

Common tests we need for this group of women, are normal full blood examination, bleeding and clotting test, a vaginal ultrasound as described in the previous posts, on AUB, saline infusion vaginal ultrasound, this will show us any polyps, intrauterine fibroids, and thinned  endometrium (Less than4 mm)  4 mm is the cut off point) Or thickened endometrium(more than 4mm).  These tests give us the correct reason for the bleeding then we can offer the precise treatment. 

Atrophic vaginitis can occur in 20 to 25% PMB women. It causes pain or bleeding with or without intercourse, it gets infected, urinary tract infections happen frequently, even without UTI, it causes pain and burning on urination. On examination this vagina seems shortened, loses its elasticity and shows minute haemorrhages. Moisturising  creams and normal domestic oils are helpful. In some cases a gentle douche with vinegar is useful. Women can use one table spoonful of vinegar in a litre of water, wash it with a pippett or can buy a proper douche can. In more severe cases oestrogen creams and tablets are used.  These are made from a very mild form of oestrogens called oestriol, it is not absorbed in the body hence no progesterone is required. However another form of local oestrogen is supplied by a string and it is placed in the upper part of the vagina , it has some risk of endometrial cancer, in this case discuss with your care giver if you need progesterone. If you are on oral HRT you may not need local treatment. Sometimes the cervix gets stenosed, and an atrophic uterus gets filled with old blood and even pus, you have to dilate the cervix, maybe do an endometrial biopsy and follow this with a short term course HRT. I have come across many cases of Haematometra and Pyometra (Blood or Pus in the uterine cavity).  When the ultrasound suggests an endometrial hyperplasia, an endometrial biopsy is performed, depending on the degree of hyperplasia and any other risk factors for endometrial cancer, in consultation with the woman either a hysterectomy with removal of both ovaries is advised or progesterone therapy is tried. If it confirms a diagnosis of endometrial cancer, it is referred to an oncologist (specialists who treat cancer patients). Endometrial polyps, some sub mucous fibroids can be treated by hysteroscopic procedures.

The important conclusion is that postmenopausal bleeding is an unexpected cause of bleeding 12 months after menopause, there is 90 % likely hood that this will be due to a benign cause but this should always be investigated urgently, as in 10% of cases it is due to endometrial cancer.  The commonest cause is vaginal atrophy, than endometrial and other polyps, others are HRT and endometrial hyperplasia which often leads to endometrial cancer, so always take it seriously.