Strategies for managing postmenopausal bleeding: a clinician's perspective

Postmenopausal bleeding (PMB) poses a diagnostic challenge due to the varied presentation of endometrial pathologies ranging from benign endometrial atrophy to the possibility of endometrial carcinoma. Although the incidence varies with patient characteristics, it warrants thorough evaluation. Risk factors such as obesity and hormone use should guide assessment. Bleeding may originate from various gynecological and non-gynecological sites, demanding meticulous history-taking and examination. Transvaginal sonography (TVS) is typically the initial step, yet its accuracy in excluding carcinoma remains debated. Invasive procedures like hysteroscopy and endometrial sampling offer higher accuracy but are more intrusive. The optimal diagnostic strategy remains uncertain, necessitating focused research for enhanced accuracy. TVS-guided assessment with an endometrial thickness (ET) threshold of >4 mm prompts evaluation and endometrial sampling. Progestogen therapy mitigates endometrial cancer risk associated with estrogen use, with atypia-hyperplasia necessitating vigilant monitoring and possible hysterectomy. Patient counselling on treatment options is crucial. In summary, PMB warrants a systematic approach integrating imaging, histological assessment, and tailored therapy guided by risk factors, final diagnosis and patient preferences.

Association of postmenopausal bleeding with endometrial cancer

Background: Uterine cancer, also clinically referred to as endometrial cancer, stands out as the most prevalent cancer within the reproductive system of women. Notably, approximately 80% of women experiencing postmenopausal bleeding (PMB) with an endometrial thickness of ?4 mm exhibit localized pathological lesions in the uterine cavity. This study aimed to assess the association of PMB with endometrial cancer.Methods: This prospective study was conducted at the department of obstetrics and gynecology, delta medical college and hospital, Dhaka, Bangladesh from July 2018 to June 2019. The study comprised 1000 patients selected through purposive sampling, adhering to specific inclusion and exclusion criteria. Microsoft office tools were employed for data processing and analysis. The analytical approach employed was descriptive in nature.Results: The study revealed that the highest percentage of patients (20.20%) exhibited abnormal endometrial hyperplasia, followed by carcinoma cervix (19.2%) and endometrial cancer (16.7%). Additionally, a significant portion of the participants, constituting 40.30%, had co-existing hypertension, while 38.1% had diabetes mellitus, and 34.0% had dyslipidemia. Notably, 65.9% of patients diagnosed with endometrial carcinoma displayed an endometrial thickness exceeding 4 mm.Conclusions: PMB is not statistically significant for endometrial cancer, but prompt evaluation is essential to exclude malignancy. Transvaginal ultrasonography (TVUS) is a reasonable first-line approach, and invasive sampling is recommended when the endometrial thickness exceeds 4 mm.

Evaluation of postmenopausal bleeding: a cross sectional study

Background: Postmenopausal bleeding (PMB) is one of the most common reasons for referral to tertiary care centres with a strong suspicion of malignancy. Endometrial cancer is the most common cause of gynaecological malignancy in the West, but in India the incidence rates are low. Eighty to ninety percent (80-90%) women have benign conditions in India. The aim and objectives of my study are to evaluate causes of PMB and sociodemographic characteristics among postmenopausal women.Methods: A hospital based analytical cross-sectional study was conducted among women above 45 years with PMB admitted in the department of obstetrics and gynaecology, regional institute of medical sciences (RIMS), Imphal. The study was conducted for a period of two years from October 2019 to September 2021.Results: In this study, out of 50 postmenopausal women 35 (70%) belong to age group >50 years and only 15 (30%) belong to age group <50 years. The most common cause of PMB in this study was found to be endometrial atrophy (12 out of 50) and two thirds of them having ET between 2-4 mm. This association is found to be statistically significant. The incidence of genital tract malignancy in our study is 14%. Incidence of endometrial carcinoma (8%) is slightly higher than cervical cancer (6%). The incidence of premalignant lesions (endometrial hyperplasia with atypia, endometrial intraepithelial neoplasia, cervical intraepithelial neoplasia) is 20% in this study. The study did not show significant association of clinical variables with benign, premalignant or malignant causes of PMB.Conclusions: With increase in life expectancy the incidence of PMB is expected to increase in future. Since the incidence of malignancy is quite high, any bleeding in that age group should be evaluated in the line of malignancy unless proved to be otherwise.

Hysteroscopy: an effective tool in post-menopausal bleeding

Background: Postmenopausal bleeding is a condition where endometrial carcinoma is to be ruled out. Traditionally, D and C is the preferred method for diagnosis in such condition. Other diagnostic modalities like trans vaginal ultrasonography (TVS) and hysteroscopy are being used for diagnosis in the cases of PMB. The objective of this study is to evaluate the efficacy and accuracy of TVS and hysteroscopy in women with postmenopausal bleeding (PMB).Methods: One hundred postmenopausal women with vaginal bleeding underwent TVS and hysteroscopy. Endometrial tissue was obtained by curettage and sent for histopathology examination. The results of TVS and Hysteroscopy were compared against HP report.Results: Hysteroscopy was successful in 98 patients. Endometrial histopathology revealed proliferative, secretory and atrophic endometrium in 26, 7 and 23 patients respectively. Polyp was diagnosed in 13 patients. Endometrial hyperplasia was detected in 11 patients and endometrial malignancy in 14 patients. All patients with endometrial hyperplasia and malignancy had ET (endometrial thickness) more than 4 mm, except one patient with endometrial malignancy who had 4 mm ET. The sensitivity and specificity of TVS for suspecting endometrial pathology at ET 4mm were 93% and 69.6%, respectively. Hysteroscopy had sensitivity of 95.2%, specificity of 92.8%, with diagnostic accuracy of 93.8%.Conclusions: Hysteroscopy was found to be the more sensitive and specific than Transvaginal sonography for diagnosing endometrial pathologies. Hysteroscopy is safe and effective for detecting endometrial pathologies in patients with PMB.