Postmenopausal Vaginal Bleeding

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Chapter 118 Postmenopausal Vaginal Bleeding

INTRODUCTION

Description: As a symptom only, postmenopausal bleeding—vaginal bleeding that occurs in women who have passed menopause—requires evaluation to rule out processes that may threaten the long-term health of the patient.

Prevalence: Common.

Predominant Age: 50 or older.

Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Systemic—estrogen, estrogen/progesterone, thrombocytopenia. Uterine—endometrial cancer, endometrial hyperplasia, endometritis, submucous leiomyomata. Cervical sources—carcinoma, cervical eversion, cervicitis, condyloma, polyps. Vaginal sources—adenosis, atrophic change, carcinoma, foreign bodies (condom, pessary, tampon), infection, lacerations (coital injury, trauma). Vulvar and extragenital sources—atrophy, condyloma, cystitis/urethritis, gastrointestinal (cancer, diverticulitis, inflammatory bowel disease), hematuria, hemorrhoids, infection, labial varices, neoplasm, trauma, urethral caruncle, urethral diverticula, urethral prolapse/eversion.

Risk Factors: Estrogen replacement therapy, others based on specific pathologic conditions.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Painless vaginal bleeding (spontaneous or iatrogenic)

• Pink or dark discharge noted on the underwear or when wiping after urination

DIAGNOSTIC APPROACH

Workup and Evaluation

Laboratory: No evaluation indicated.

Imaging: Saline infusion ultrasonography (sonohysterography) may allow measurement of endometrial thickness and the possibility of endometrial polyps. Transvaginal ultrasonography may be used to assess endometrial thickness. (No standard has emerged for a threshold of endometrial thickness that carries ideal positive and negative predictive values. Recently published data suggest that when the endometrial thickness is less than 5 mm, endometrial biopsy is not required.)

Special Tests: Endometrial biopsy should be strongly considered to evaluate the cause and to check for the possibility of a malignancy.

Diagnostic Procedures: History and physical examination, cervical cytologic examination, endometrial sampling.

Pathologic Findings

Varies with cause.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation.

Specific Measures: Based on cause identified.

Diet: No specific dietary changes indicated.

Activity: No restriction.

Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP162 (Menopausal Bleeding), AP025 (Ultrasound Exams), AP047 (The Menopause Years), AP066 (Hormone Therapy).

Drug(s) of Choice (Based on Pathophysiologic Condition Present)

In many cases of postmenopausal bleeding, the endometrium is thin and atrophic. This endometrium is prone to irregular slough, resulting in erratic, although generally light, bleeding. Because the endometrial tissue is so denuded, it does not respond well to progestational agents. Estrogen, alone initially or in combination with progestin therapy, is required to induce initial growth and the development of progestin receptors to effect endometrial stabilization.

FOLLOW-UP

Patient Monitoring: Postmenopausal bleeding should be presumed to indicate the presence of a malignancy, until proved otherwise. The only exception to this is the withdrawal bleeding that occurs as a part of cyclic estrogen–progesterone hormone therapy.

Prevention/Avoidance: None.

Possible Complications: Progression of undiagnosed malignancy.

Expected Outcome: If diagnosis is prompt and appropriate therapy is instituted, the outcome should be excellent.

MISCELLANEOUS

Pregnancy Considerations: Not applicable.

ICD-9-CM Codes: 627.1.

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