Vaginal bleeding

Postmenopausal bleeding

• Definition & Etiology:
  • Definition: Vaginal bleeding ≥ 12 months after menopause.
  • Most Common Cause: Endometrial/vulvovaginal atrophy (~60–80%).
  • Most Concerning Cause: Endometrial carcinoma (EC) (~10%) – must be ruled out in all cases. c
  • Other Causes: Endometrial polyps, endometrial hyperplasia (EH), Tamoxifen, hormone therapy, estrogen-secreting ovarian tumors (Granulosa cell).
• Risk Factors for Malignancy (Unopposed Estrogen):
  • Obesity (peripheral estrone conversion by aromatase).
  • Tamoxifen use.
  • Lynch syndrome (HNPCC).
  • Nulliparity, early menarche, late menopause, chronic anovulation (PCOS).
• Diagnostic Workup Algorithm:
  • Step 1 (Initial Test): Choose either Transvaginal Ultrasound (TVUS) or Endometrial Biopsy (EMB).
    • TVUS findings:
      • Endometrial stripe ≤ 4 mm: Malignancy effectively excluded (>99% NPV) → observe or treat for atrophy; re-biopsy if bleeding recurs.
      • Endometrial stripe > 4 mm or heterogeneous/focal: Proceed to EMB.
    • EMB: First-line alternative directly, especially if high-risk pt (e.g., Lynch, severe obesity, Tamoxifen).
  • Step 2 (Definitive / Next Step if EMB Fails):
    • Hysteroscopy with D&C indicated if:
      • EMB is non-diagnostic/insufficient tissue with persistent bleeding.
      • Cervical stenosis prevents EMB.
      • Focal lesion/polyp identified.
• Management by Etiology:
  • Atrophy: Non-hormonal vaginal lubricants/moisturizers → low-dose topical/vaginal estrogen.
  • Endometrial Polyps: Hysteroscopic polypectomy.
  • Hyperplasia without atypia: Progestins (LNG-IUD or oral medroxyprogesterone) + repeat EMB in 3–6 months.
  • Hyperplasia with atypia (EIN): Total Hysterectomy with Bilateral Salpingo-oophorectomy (TH-BSO) (due to ~30–40% concurrent cancer risk).
  • Endometrial Carcinoma: TH-BSO + surgical staging (lymph node evaluation) ± adjuvant chemo/radiation.