|
Postmenopausal
bleeding - i.e. bleeding after one full year without a period.
All postmenopausal
bleeding is considered to be caused by cancer until proven otherwise!
However, it most likely
is caused by something else - as shown in the chart below
From http://www.theberries.ns.ca/Archives/DUB2.html
|
Etiology of Postmenopausal
Bleeding
|
| Cause |
Percentage
|
| Exogenous Estrogen |
30
|
| Atrophic Endometritis/Vaginitis |
30
|
| Endometrial Cancer |
15
|
| Endometrial or Cervical
Polyps |
10
|
| Endometrial Hyperplasia |
5
|
| Misc. (CxCa, sarcoma, trauma,
urethral caruncle.) |
10
|
3. All patients need endometrial
sampling!
To see Flow
chart for endometrial sampling and other management points visit above
URL
Another Canadian source
detailing procedures to follow is the
PRACTICE GUIDELINES POLICY
STATEMENT* No. 86, February 2000 from the Canadian Society of Gynecologists
and Obstetricans which can be downloaded from
http://sogc.medical.org/SOGCnet/sogc_docs/common/guide/pdfs/ps86.pdf
Diagnosis of Endometrial
Cancer in Women with Abnormal Vaginal Bleeding
[Extract
only]
RECOMMENDATIONS
-
Office endometrial biopsy should
be the initial diagnostic procedure of choice due to its convenience, accuracy,
availabil-ity, safety and low cost (Grade B).
-
If an office endometrial biopsy
cannot be performed or the sample is insufficient, then patients should
be triaged according to their risk for endometrial cancer. Those felt to
be at low risk for endometrial cancer or in whom atrophy is suspected or
who are medically unfit, should proceed to transvaginal ultrasound. Those
at high risk (i.e. obese, nulliparous, post-menopausal, diabetic women,
or those taking tamoxifen) should proceed to D&C, with or without hysteroscopy,
as a negative ultrasound would not necessarily be completely reassuring
and a positive ultrasound would require tissue sampling regardless (Grade
B).
-
There is no consensus in the
literature as to what the cut-off value for normal endometrial thickness
should be. It has been reported as anywhere from four mm to eight mm. Obviously,
the lower the cut-off, the higher the sensitivity for detection of such
abnormalities as endometrial cancer or its precursors, but at a cost of
lower specificity (Grade B).
-
Persistent bleeding after negative
initial evaluation should not be ignored, and should be investigated further,
as at least 10 per-cent of patients will harbour disease (Grade C).
-
Patients taking continous combined
HRT who experience vaginal bleeding after the first six months of therapy
should be investigated with an endometrial biopsy, as should patients on
sequential HRT who experience bleeding outside the expected time, i.e.
after completing their progesterone (Grade B).
-
Patients taking tamoxifen who
experience vaginal bleeding should be investigated with endometrial biopsy
(Grade B).
Individual recommendations have
been graded according to the level of evidence on which they are based:
Grade A: Randomized trials.
Grade B: Other robust experimental
or observational studies.
Grade C: More limited evidence,
but the advice relies on expert opinion and has the endorsement of respected
authorities.
For more about unexpected
bleeding while on HRT see the "While on HRT" link below.
An American viewpoint
on Postmenopausal Bleeding - What Diagnostic
Work-up?can be read at http://www.xtn.net/com/uppgobg/nbleed.htm#pmbhrt
It mentions D&C
and compares the value of endometrial biopsy with that of transvaginal
ultrasound. |