As with most malignancies, early diagnosis may lead to a better prognosis. EIN is considered a cancer precursor. Journal of minimally invasive gynecology. Complementary therapies in clinical practice. Nursing Diagnosis. [7], The diagnostic accuracy of endometrial sampling correlates positively with the amount of tissue that is collected. Mediators of inflammation. Without atypia, gland cytology is normal, and only occasional mitotic figures are found. Systemic estrogen-only therapy, chronic anovulation (such as in polycystic ovarian syndrome), obesity, and estrogen-secreting tumors can lead to abnormal endometrial changes. European journal of obstetrics, gynecology, and reproductive biology. 2 Because 90% of PMB is associated with a benign condition, the ideal diagnostic method is noninvasive. Fogorvosi szemle. The stroma between glands is inactive. [24], Endometrial Hyperplasia or Malignancy: Can be managed medically or surgically, depending on the severity. How is postmenopausal bleeding diagnosed? Wong AW, Lao TH, Cheung CW, et al; Reappraisal of endometrial thickness for the detection of endometrial cancer in postmenopausal bleeding: a retrospective cohort study. Explain the differential diagnosis of postmenopausal bleeding. There can be several causes of postmenopausal bleeding. 1998 Aug 1;     [PubMed PMID: 9690359], Matsuo K,Ramzan AA,Gualtieri MR,Mhawech-Fauceglia P,Machida H,Moeini A,Dancz CE,Ueda Y,Roman LD, Prediction of concurrent endometrial carcinoma in women with endometrial hyperplasia. [17][18] Office endometrial biopsy can also be performed using metal curettes or flexible plastic samplers. Care of gynecologic malignancies, including uterine or endometrial cancer and precancer, should be coordinated with gynecologic oncologists. Chronic endometritis can be secondary to atrophy or infection. Inherent coagulopathies 7. Constipation can be treated with hydration, stool softeners, etc. Before menopause women have periods every 21-30 days, or monthly. [7] An endometrial thickness of less than or equal to 4 mm has a negative predictive value greater than 99% for endometrial carcinoma. An early diagnosis can make a world of difference when treating cancer. Journal of minimally invasive gynecology. The shape, size, and tenderness of the uterus can aid in narrowing the differential diagnosis. The GP should refer you to hospital or a special postmenopausal bleeding clinic. Endometrial polyps are often benign, but they can contain hyperplasia or malignancy approximately 5% of the time. Blind sampling may miss focal lesions or intrauterine pathology, such as polyps. Removal is recommended, especially in patients with symptoms or at risk of malignancy (larger polyps, tamoxifen use, obesity, diabetes).[23]. [11] Loss of vaginal elasticity and rugae can lead to narrowing and shortening of the vagina. Hemorrhagic cystitis or proctitis can be significant. Over the last two decades, the role of ultrasound in the evaluation of postmenopausal bleeding has changed markedly, from little or no role in 1990 to a major role today. Close menu. Treatment depends on what's causing your bleeding. Providers should ask postmenopausal patients about bleeding at their routine appointments, rather than depending on them to volunteer the information. Lastly, a general systemic examination is essential to identify signs of chronic or severe illness. The glands become cystic, appearing large and round. Decision made to separate PMB and endometrial cancer. Postmenopausal Bleeding Causes, Risks Factors, Diagnosis and Treatment Any bleeding after menopause is abnormal and should be reported to a gynecologist. The patient is considering non-surgical management. JAMA. A thickened endometrial lining greater than 4 mm, Diffuse or focally increased echogenicity or heterogeneity, The inability to visualize the endometrium adequately, Patient understands and accepts the fact that data on outcomes (pregnancy-related and cancer-related) are limited, Well-differentiated endometrioid endometrial carcinoma, grade 1, No contraindications to medical management, Atrophy: Lack of estrogen can lead to bleeding from within the uterine cavity or from the vagina or vulva if lacerations or fissures occur, Malignancy: Cancer may bleed from the fragility of the blood vessels within it or invasion into nearby blood vessels, Polyps: Bleeding may be due to apical necrosis and venous stasis caused by stromal congestion inside the, Uterine Leiomyomata: Can put pressure on the opposing uterine walls or endometrial, or disrupt the normal vasculature of the uterine myometrium, Adenomyosis: May disrupt the tissues of the myometrium and endometrium, Infection: Can cause inflammation and irritation, leading in turn to bleeding, Endometritis: Can be infectious (see above), or noninfectious secondary to epithelial micro-erosions leading to chronic inflammation, Herbal Supplements: Phytoestrogens may stimulate the endometrial lining and subsequent bleeding, Anticoagulation: Can lead to increased bleeding than would otherwise be seen in a given situation. Fertility and sterility. Gastrointestinal disorders (e.g., varices, polyps ,ulcer) 5. There are currently no recommendations from governing bodies such as the American College of Obste… Fragile tissues may tear and bleed or lead to fissures. Some patients with endometrial hyperplasia may have undiagnosed concurrent endometrial carcinoma. It is generally acknowledged that the prognosis is better for patients with gynecologic malignancies who are cared for by gynecologic oncologists. Suppose atypia is present, as, in endometrial intraepithelial neoplasia (EIN), both gland crowding and abnormal gland nuclei are seen. It is diagnosed traditionally on histology by plasma cell infiltration. If hormone regimens include progestins, bleeding may be an intended result (cyclical therapy regimens) or a result of hormonal imbalance. Uterine bleeding is necessary monthly because human females are fertile once a month, they prepare … Postmenopausal hormone therapy may also lead to uterine abnormalities as above, and if so, they should be treated as indicated. Introduction. The doctor may conduct a pelvic exam for cervical cancer. Past Medical History: The patient’s past medical history may be helpful. A urologist may be more appropriate; on the other hand, if the bladder or urethra is the cause of bleeding. Postmenopausal bleeding is often successfully treated. The American College of Obstetricians and Gynecologists recommend transvaginal ultrasound for initial evaluation. Endometrial cancer is staged as follows:[9], Stage I: The tumor is limited to the uterine corpus, Stage II: The tumor invades the cervical stroma but doesn't extend beyond the uterus, Stage III: The tumor has spread locally or regionally, Stage IV: The tumor has invaded bladder, bowel, or has spread distantly, Overall the prognosis of postmenopausal bleeding is favorable because the most common etiologies are benign. A specialist, who may be a nurse, will offer you tests to help find out what's causing the bleeding and plan any necessary treatment. Gynecologic oncology. Over 70% of endometrial cancer cases are diagnosed at stage I, with an associated survival rate at five years of 90%. Atrophy: Bleeding is usually self-limited and requires no treatment. 1 The top three diagnoses associated with PMB are endometrial atrophy (40% to 50%), endometrial cancer (10%), and polyps (3%). 2.2 July 2011 Separated documents … Atrophic endometrial cells, on the other hand, are smaller and more cuboidal than proliferative endometrium. Submucous Leiomyoma: Fibroids may be removed hysteroscopically or laparoscopically, or they may be ablated with various devices (some currently investigational). Cervical Cancer: Treatment is based on stage and may include surgery or radiation. Perimenopausal patients should be counseled regarding expectations for the menopausal transition years. Other ways the doctor may diagnose postmenopausal bleeding include: Sonohysterography; The doctor can check if the uterus lining is thinner or thicker than expected with this procedure. Though endometrial cancer, when diagnosed in early stages, has a good prognosis, later-stage endometrial cancer has a poorer prognosis. There are multiple etiologies for this common complaint in which most are benign such as cervicitis or cervical polyps. Conclusion. Care must be taken to solve these issues after evaluation for more life-threatening etiologies is done. In a postmenopausal woman with an intact uterus, an episode of vaginal bleeding is indicative of endometrial hyperplasia and is suspicious for endometrial cancer. The nurse is teaching a postmenopausal client about osteoporosis prevention. are important clues to the etiology of the bleeding. Author(s) / Contributors Disclosure of Conflicts of Interest. Also, with regards to social history, cigarette smoking may increase the risk of bladder cancer (hematuria may be mistaken for vaginal bleeding) but decreases the risk of endometrial cancer. Evidence is present of endometrial cancer spread to the cervix or outside the uterus (lymph nodes, ovary). [6] About 1-14% of postmenopausal bleeding will be secondary to endometrial cancer. Postpartum complications (e.g., retained placenta, uterine atony) 8. 17,18. Histology preoperatively is a high risk for extrauterine spread (grade 3, clear cell, papillary serous, carcinosarcoma). 631: Endometrial Intraepithelial Neoplasia. Post-Radiation Effects: Devascularization of radiated tissues can lead to necrosis, perforation, tissue sloughing, and bleeding. Obstetrics and gynecology. 2, 3 Transvaginal sonographic measurement of endometrial thickness is used to distinguish between women with a low or high risk of endometrial cancer. The heaviness of bleeding, number of bleeding days, and the constancy or intermittent nature of bleeding is also essential. History of Present Illness: The nature of the patient’s prior menses and current bleeding are both essential historical elements. Approximately 16% to 18% of postmenopausal women develop urinary incontinence. Longer-term solutions may need to be discussed in patients on lifelong anticoagulation. Therefore, all women who have bleeding after reaching menopause should undergo evaluation. For example, a history of obesity, polycystic ovarian syndrome or other anovulation, diabetes mellitus, or tamoxifen use may all increase suspicion for hyperplasia or malignancy. WebMD explains possible causes of bleeding, which should always be checked out by a doctor. 2014 Dec;     [PubMed PMID: 25461364], Sasaki LMP,Andrade KRC,Figueiredo ACMG,Wanderley MDS,Pereira MG, Factors Associated with Malignancy in Hysteroscopically Resected Endometrial Polyps: A Systematic Review and Meta-Analysis. The prevalence of postcoital bleeding ranges from 0.7 to 9.0 percent of menstruating women. Both of these have been determined to be adequate methods for endometrial sampling. 1991 Nov;     [PubMed PMID: 1957847], Ricciardi E,Vecchione A,Marci R,Schimberni M,Frega A,Maniglio P,Caserta D,Moscarini M, Clinical factors and malignancy in endometrial polyps. A woman is labeled menopausal if she has gone twelve months without menses. [22] Because of this, complete hysteroscopic removal should be considered. Therefore, a postmenopausal woman with vaginal bleeding should be promptly and appropriately … This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Because postmenopausal bleeding can be the presenting symptom of endometrial cancer, any woman with this symptom should be evaluated to diagnose or exclude carcinoma. Except for being a diagnostic method hysteroscopy, is also an outpatient minimally invasive surgical procedure for treating the cause of bleeding in the majority of cases in the same sitting. 2004 Feb;     [PubMed PMID: 14756741], Rossouw JE,Anderson GL,Prentice RL,LaCroix AZ,Kooperberg C,Stefanick ML,Jackson RD,Beresford SA,Howard BV,Johnson KC,Kotchen JM,Ockene J, Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. Postmenopausal hormone therapy, depending on the regimen, may lead to bleeding. Causes of postmenopausal bleeding: Thinning of the endometrium (lining of the uterus) called endometrial atrophy On histology, one may see solid areas, maze-like glands, or appreciable cribiforming. The appropriate specialist should manage concerns for bleeding from renal etiologies or bladder masses/malignancy. Endometrial cancer cases that involve extra-uterine spread account for more than half of uterine cancer-related deaths and have survival rates as low as 5 to 15%.[11]. Postmenopausal bleeding is a common complaint with a broad differential, which includes both benign and malignant conditions. For patients with insufficient sampling, or with persistent vaginal bleeding in whom focal lesions may have been missed, additional evaluation should be considered. SAGE open medicine. Dilation and curettage has been used for years and has a sensitivity for endometrial cancer exceeding 90%. Menopause (New York, N.Y.). Menopause is usually diagnosed in women over 45 who have not had a period for more than a year. Cancer. At the patient’s initial procedure, the option to adequately surgically stage is not available. Pregnancy complication (e.g., premature rupture of membranes, placenta previ… [7] It is reasonable, to begin with, endometrial sampling first rather than ultrasound, in patients with a higher pretest probability for malignancy. A woman who has not had a period for a full year after the age of 40 is considered to be in menopause. [28] [Level 2], Smith PP,O'Connor S,Gupta J,Clark TJ, Recurrent postmenopausal bleeding: a prospective cohort study. To contact your GP surgery: Find out about using the NHS during coronavirus. The rate of postmenopausal vaginal bleeding during the study period peaks at the age of 55–59 years (25.9/1000 postmenopausal women/year) and declines thereafter. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that. Atrophy, though benign, can lead to decreased quality of life, decreased sexual intimacy, and lowered self-esteem. A history of radiation exposure is essential to elicit. [19][20][21], It is common for endometrial sampling to result in findings that are insufficient for diagnosis, with rates of sampling failure up to 54%. Hematuria: Acute cystitis may be treated with antibiotics. 2008 May;     [PubMed PMID: 18396257], Unfer V,Casini ML,Costabile L,Mignosa M,Gerli S,Di Renzo GC, Endometrial effects of long-term treatment with phytoestrogens: a randomized, double-blind, placebo-controlled study. Vulvar and vaginal atrophy may be treated with lubricants during intercourse, topical hormones (estrogen, DHEA), oral hormonal receptor modulator (ospemifene), etc. While these etiologies all lead to bleeding from a uterine source, they must be distinguished from non-gynecologic bleeding as above. What information should the nurse include when teaching this client about osteoporosis prevention? It accounts for approximately 5 percent of office gynecology visits . Human reproduction (Oxford, England). Nederlands tijdschrift voor geneeskunde. 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding. Medications: Knowing a patient’s medications is important. Postmenopausal Hormone Therapy: Estrogen may cause the proliferation of the endometrium, leading in turn to hyperplasia or malignancy. 2010 Sep;     [PubMed PMID: 21058493], Sany O,Singh K,Jha S, Correlation between preoperative endometrial sampling and final endometrial cancer histology. Less commonly, postmenopausal bleeding is caused by cancer, such as ovarian and womb cancer. 2014 Sep-Oct;     [PubMed PMID: 24681065], Astrup K,Olivarius Nde F, Frequency of spontaneously occurring postmenopausal bleeding in the general population. 2004 Oct;     [PubMed PMID: 15763777], ACOG Committee Opinion No. Gastrointestinal Bleeding: Bleeding hemorrhoids may be managed with topical treatments or with removal. This counseling can include how to manage menopausal symptoms, vaginal dryness, changes in metabolism, osteoporosis prevention, etc. 2018 Jul - Aug;     [PubMed PMID: 29454147], Di Caprio R,Lembo S,Di Costanzo L,Balato A,Monfrecola G, Anti-inflammatory properties of low and high doxycycline doses: an in vitro study. Physical Exam: On physical exam, it is crucial to perform a thorough evaluation of the internal and external anatomy of the genital tract. If anticoagulants are leading to vaginal bleeding, medical management with progestins may control bleeding until the anticoagulant course is complete. European journal of gynaecological oncology. Proper diagnosis and treatment can improve a patient’s quality of life. In 2017, there were over 61,000 new cases of uterine cancer; there were almost 11,000 deaths. [7] The endometrial thickness is measured in an anterior-posterior fashion, at the area of endometrial echo of maximal thickness, on a long-axis view of the uterus. 2002 Jul 17;     [PubMed PMID: 12117397], Smith-Bindman R,Weiss E,Feldstein V, How thick is too thick? Polyp: Removal of the polyp may resolve the bleeding. A pelvic ultrasound would reveal a normal-appearing small postmenopausal uterus, small postmenopausal ovaries, and a thin endometrial stripe. Postmenopausal bleeding is the situation similar to menstrual cycle for all the women that are reached to menopause. [7] Most cases of uterine cancer are endometrial in origin (92%). Failure to evaluate postmenopausal bleeding may lead to delayed diagnosis of endometrial cancer. Ovarian, fallopian tube cancers, and uterine sarcomas require subspecialist care. 169. If a subsequent transvaginal ultrasound shows a thin endometrium, and if bleeding has stopped, no further evaluation is necessary.[7]. 141: Management of Menopausal Symptoms: Correction. Guideline for the Management of Post Menopausal Bleeding (PMB) formerly the guideline for PMB and endometrial cancer Version History Version Date Summary of Change/Process 2.0 February 2008 Endorsed by the Governance Committee 2.1 July 2011 Circulated at NSSG meeting. Review the recommendations for the evaluation and management of postmenopausal bleeding. Postmenopausal bleeding is defined as uterine bleeding after a woman has been menopausal for a year or more. 2006 Dec;     [PubMed PMID: 16876234]. 2015 Nov;     [PubMed PMID: 26238457], Díaz-Montes TP,Zahurak ML,Giuntoli RL 2nd,Gardner GJ,Bristow RE, Uterine cancer in Maryland: impact of surgeon case volume and other prognostic factors on short-term mortality. On the other hand, premalignant or malignant conditions of the endometrium often arise after unopposed estrogen.
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