Postmenopausal bleeding

Aymen zemmal (10110068)

contents

• SOEPEL.• Brief illustrate of terms related to menopause.• Menopause: age, pathophysiology, hormone

level, anatomical changes, menopausal symptoms and treatment.

• Postmenopausal bleeding: etiology, clinical features, diagnosis and investigations.

• Management.

SOEPEL• Wadha is 54 years old saudi from oneiza is house wife and

mother of 2 sons and 8 daughters.• Chief complain: vaginal bleeding, abdominal pain and

diarrhea.• History of presenting illness: slight vaginal bleeding since 1

day, lower sudden moderate progressive abdominal pain not radiated since 1 day the diarrhea frequency is more than 10 time not associated with blood or mucus since yestreday.

• Past history: medical: arthritis and right hand swelling. surgical: cessarian section and hysterectomy since months due to 2 kg fibroid uterus. OBG: menorrhagia. medications: allergies

• Family history: no• Social history: healthy house wife and her husband is

smoker.• Review of systems: GI: slight neasea, no fever, lower abdominal pain diarrhea.no weight loss and no vomit.

OBG: menstrual history: menache 13 menopause: no just after hysterectomy. LMP:2 months. cycle length and frequency:28/6 postmenopausl bleeding: slight vaginal bleeding. postcoital bleeding.

• Discharge: yellowish slight not iching and no resh since 2 days.

• Abdominal pain: bowel problems here diahrea is due to unheaten mild.

dyspareunia

prolapse Urinary symptoms:Obstetric history: 2 sons and 8 daughters got normal vaginal delivery except last one got cessarian section.

contraceptions:Sex relationships:Infections:

SOEPEL

• Object: GE: HR is 80. coulour, respiration is 18 term: 37. BP is 70/139. no alarm signs such abdominal examination especially palpation will reveal if there is a tumor.Gynae examination: speculum and bimanual examinations.

SOEPEL• Evaluation: DD: vulva: vulvitis, benign and malignant lesions and cancer. vaginal tumor: benign or malignant or foreign body.

SOEPEL

• Plan: investigations and diagnostic techniques. CBC ultrasound laparscopy if ultrasound pick a pelvic tumor. biobsy.

Learning goals: postmenopausal bleeding.

Important terms related to menopause

• Perimenopause: is period of 3-4 years before menopause and followed by a year of amenorrhea.

• Menopause: timed of cessation of ovarian function resulting in permenant amenorrhea. It take 12 months to confirm that it is menopause.

• Late menopause: menstruation continues beyond 52 year sometimes it is normal due to healthy habits, and due to developed ovarian cancer or fibroid.

• Postmenopausal bleeding: normaly after 1 year of amenorhea vaginal bleeding is occuring.

menopause• Occuring between 45-50 years average is 47

years.• It is difficult to see women after age of 50

menstruate well this delayed menopause could be due to good nutrition.

• Menopausal age differences is not related to menarche race, socioeconomic status, number of pregnancies and lactation or usage of oral contraceptives. ( who agree?)

pathophysiology• Ovarian activity decline, initially ovulation fails so, no

corpus luteum and no progesterone secreted in ovary. So, the premenopausal cycles are often anovulatory and irregular.

• later, grafian follicle fails to develop estrogenic activity reduction and endometrial atrophy leads to amenorrhea.

• Homones levels: 50% reduction in estrogenic production.66% reduction in estrogen at menopause. E2, oestrone, FSH, androgens, testesterone, LH and androsternedione.:

Risk factors for menopause related diseases

• Early menopause.• Surgical menopause.• Chemotherapy especially alkalytic agents.• Smoking, caffeine and alcohol.• Family history of menopausal diseases.• Drugs such GnRH, heparin, corticosteiroids, and

clomphene(anti-estrogen)when given over prolonged period( anti estrgenic) can lead to estrogenic deficiency.

• Atrophy and regression of genital organs.• Menopausal symptoms: sudden cessation,

gradual decrease of menses until to stop and gradual of length of cycle.

• 60 to 70% without symptoms.• Hot flushes: waves of vasodilation affect face

and neck last for 2-5 minutes each followed by severe sweating.

• Irritability an lack of concentration.• Paresthesia.

• Libido changes.• Dysuria without infection.• Lately: arthritis, osteoporosis, cardiovascular,

stroke, skin changes, prolapse of genital tract.• Treatment HRT which protect against osteoporosis, cardiovascular symptoms, stroke, alzheimer disease and colonic cancer.

Postmenopausal bleeding• Normally 1 year of amenorrhea then vaginal

bleeding occuring after 6 months of amenorrhea.• Etiology: vulva: trauma, vulvitis, benign and malignant lesions.Cervix: cervical erosion, cervicitis, polyp, decubitus, ulcer in prolapse and malignancy.Uterus: senile endometriosis, tubercular endometritis

• Ovary:• Fallopian tube malignancy.• Hypertension or anemia.• Urinary tract• Bowel problems

Clinical features• Abdominal pain.• Foul smelling discharge noticed in malignant

tumors.• Bleeding painless.• Urinary and rectal symptoms.

Diagnosis and investigation• GE: vital signs and alarm signs.• Abdominal and gynacological examination.• Investigations: CBC, ultrasound, hysteroscopy, laparscopy and biobsy.

Management and treatment

• Treat the cause first.• Patient should be kept under observation

(warding).