what is menopause?
permanent cessation of menstruation resulting from loss of ovarian follicular activity
when can menopause be diagnosed?
after 12 consecutive months of amenorrhoea
what is post menopausal bleeding?
vaginal bleeding occurring at least 12 months after the last menstrual period
when is PMB normal?
if on combined cyclical HRT, bleeding in the progesterone free period is normal
what is the cause of PMB in most cases?
atropic vaginitis where vaginal epithelium thins and breaks down in response to low oestrogen levels
what 4 things do you want to exclude if pt presents with PMB?
- 1. endometrial carcinoma
- 2. cervical carcinoma
- 3. pre-malignant endometrial hyperplasia with cytological atypia
- 4. ovarian carcinoma
what are the non-cancerous causes of PMB?
- 1. atrophic vaginitis: poorly oestrogenised vaginal wall
- 2. cervicitis
- 3. cervical polyp
- 4. endometrial polyp
- 5. withdrawal bleed from HRT
- 6. foreign body eg pessary
what Qs need to be asked in history of PMB?
- 1. bleeding: when, frequency, quantity, how many pads, consistency - clots or spotting, colour
- 2. trauma: post coital, insertion of pessary or tampon
- 3. smear
- 4. obs: gravida and parity
- 5. PMH: diabetes, PCOS, obesity (increase risk of PMB)
- 6, pain?
what are the risk factors of endometrial cancer?
- 1. obesity
- 2. HRT
- 3. nulliparity
- 4. PCOS
- 5. tamoxifen
- 6. HNPCC gene
- 7. diabetes
what examinations need to be done in PMB?
- 1. abdominal: mass, tender, fluid
- 2. speculum cuscos: vulval lesions or trauma, look at vagina and cervix for tears, polyps, ulcers, cancer, inflammation, atrophic vaginitis, discharge,
- 3. take swabs as BV common
- 4. look for foreign bodies eg ring pessary
- 5. bimanual examination
- 6. smear test
- 7. pipelle biopsy
what will atrophic vaginitis look like on examination?
- 1. pale
- 2. thin
- 3. flattened, no rugae
what do you look for on bimanual examination?
- 1. vulva labia, varicose veins, lacerations, trauma, warts
- 2. introitus
- 3. vaginal walls
- 4. cervix: position, length, consistency, excitation
- 5. uterus: position, size, mobile,
- 6. adnexal masses
- TENDERNESS anywhere
what investigations are needed in PMB?
- 1. ultrasound ALL women with PMB: transvaginal US. check size of uterus, endometrial thickness and adnexal masses.
- 2. hysteroscopy and endometrial biopsy if on tamoxigen or >5mm or recurrent PMB
what is normal thickness of endometrium in post menopausal state?
< 5mm. then endometrial biopsy is not needed
which type of ovarian pathology can lead to PMB and why?
granulosa cell tumour: as it is hormone producing and can cause endometrium to bleed