Hello. Now, we'll review postmenopausal bleeding, causes, evaluation,
and management. Remember, postmenopausal bleeding is never normal.
Let's discuss when menopause occurs.
We have another lecture about menopause if you'd like to review that.
The average age of menopause is 51 years old.
Remember, this is a retrospective diagnosis and requires no menstrual cycles
for at least 1 year. Any bleeding that occurs after the menopause
requires a prompt evaluation. This is never a normal phenomenon.
Let's now review the epidemiology of postmenopausal bleeding in the US.
The majority of patients will present to you a postmenopausal bleeding
due to atrophic changes in vagina or the endometrium.
However, remember that cancer of the endometrium can occur
and it's the most common type of gynecologic cancer in the US.
Depending on age and risk factors, that is older age and risk factors
such as obesity and chronic anovulation, 1-14% of patients
will have endometrial cancer.
Let's now discuss the common causes of postmenopausal bleeding.
Endometrial atrophy is the most common cause.
After the menopause, which again occurs at 51 years of age on average,
the endometrium may become too thin as result of low estrogen levels
However, polyps are another cause.
Polyps are usually a noncancerous growth of tissue in the endometrium
that actually can cause some bleeding.
Endometrial hyperplasia is another common cause of postmenopausal bleeding.
Essentially, the lining of the uterus thickens and that leads to hyperplasia
which is the precursor to endometrial cancer.
Endometrial hyperplasia is more common in obese women
as they have peripheral aromatization of androgen making estrogens
and they have unopposed estrogenic state.
ACOG recommends that all patients be evaluated with a transvaginal ultrasound
or an endometrial biopsy.
Let's now discuss the management of postmenopausal bleeding.
If a patient has endometrial carcinoma, they should be referred to a GYN oncologist
and have a hysterectomy. Likely these patients will have already be
of postmenopausal age but young patients can even have endometrial carcinoma.
Endometrial hyperplasia is typically treated with progestins
that can be in the form of a levonogestrel IUD or oral progestins.
Atrophy is typically treated with hormone replacement therapy,
either transdermally or locally in the vagina.
If polyps are present, they should be removed hysteroscopically
which is a same day procedure and is not terribly invasive.
For more information about polyps, look at the lecture regarding AUB, specifically AUBP.
Let's now talk about Tamoxifen use in the postmenopausal women.
Some women in their postmenopause and perimenopause
can still be on Tamoxifen therapy as result of having ER-positive breast cancer.
This has been known to cause endometrial hyperplasia
but we shouldn't just screen patients who are on Tamoxifen
unless they present with bleeding.
Let's now review what we've discussed.
Endometrial and vaginal atrophy are the most common cause.
Always evaluate postmenopausal bleeding, that means the patients requires
a history physical exam and evaluation.
Transvaginal ultrasound and endometrial biopsy are both first line methods
of evaluation as recommended by ACOG.
Persistent bleeding needs reevaluation despite initial benign findings
as there may be another cause that can cause postmenopausal bleeding.
90% of endometrial cancer presents with postmenopausal bleeding
and therefore it's important that we evaluate each incidence
of postmenopausal bleeding. However, there are some patients
who've undergone endometrial ablation and they may not present with bleeding.
Thank you for listening and good luck on your exam.