The Significance of Bleeding after the Menopause
Bleeding after the menopause or "post-menopausal bleeding" ("PMB") can be defined as the resumption of vaginal bleeding at least 6 months after a woman experiences her last menstrual period. This assumes of course that she is indeed menopausal ie. in her late 40's, perhaps having hot flashes and night sweats, mood swings, insomnia, perhaps experiencing some vaginal dryness. The bleeding pattern most women experience as they approach menopause is one where the periods become lighter, shorter in duration, and the interval between periods changes so that the periods are either somewhat closer together (between 21-26 days apart) or intervals greater than her customary 28 days. Cycles may be missed entirely for a couple of months.
There are many causes of postmenopausal bleeding, and the most common is hormone replacement therapy. Women who are taking hormone replacement therapy very often may develop PMB because the uterine lining is very sensitive to estrogen, which promotes growth of the endometrium, just as it does in the normal reproductive cycle that was operative prior to menopause. Lack of estrogen, on the other hand, may cause atrophy of the lining, and in this condition, the blood vessels of the uterine lining become so fragile because of estrogen lack that they spontaneously break and then bleed.
Polyps and fibroids are common benign growths that develop in the uterine cavity. The former is most often associated with irregular light spotting, staining or actual light bleeding. The latter may also present this way, but in fact may be associated with much heavier bleeding.
Overgrowths of the uterine lining are called "hyperplasias", may be the cause of abnormal post-menopausal bleeding, Some specific types are associated with a malignant potential. About 20 % of true post-menopausal bleeders may have cancer of the endometrium (the uterine lining)
What should one consider doing for the diagnosis of post-menopausal bleeding? The first thing to consider is always the medical history. Is the patient taking hormones or not? Does she have a history of known uterine fibroids? A thorough pelvic examination of the vulva, vagina and cervix (including a PAP smear) should exclude causes in the lower genital tract. A uterine biopsy requires the passing of a small tube-like device through the cervix and into the uterine cavity, suction is applied and small fragments of tissue are removed for microscopic examination. Alternatively, the Doctor might order a special ultrasound examination, as this study can delineate the thickness of the uterine lining, and perhaps the presence of a polyp or fibroid. Thickened endometrial lining can be seen spontaneously without significant underlying pathology, as a result of hormone therapy, in cases of hyperplasias or cancer, or because of other benign growths. One must remember that ultrasound examinations are the sophisticated interpretations of "shadows" and do not make an absolute diagnosis, as is the case with microscopic analysis. Thus, an abnormal ultrasound examination requires further investigation.
Hysteroscopy is a special test that entails the passing of a tiny telescope through the cervix allowing the actual visualization of the uterine cavity. Fibroids or polyps can be seen and removed, and suspicious area of tissue biopsied under direct vision.
A "D&C" is an old essentially obsolete procedure whereby a sharp spoon-like instrument is passed blindly through the cervix, and a scraping of the lining is performed in order to obtain tissue for microscopic analysis. More often than not, because it is truly a blind procedure, polyps and fibroids will be missed, as well perhaps as an early cancer. Hysteroscopy is far more precise and accurate. In this author's opinion, a "D&C" should be used only to evacuate the products of conception from the uterine cavity at the time of a miscarriage. A "D&C" is marginally useful for establishing an accurate diagnosis in the case of post-menopausal bleeding and is almost worthless for treatment.
What about treatment options? This of course depends on the cause of the bleeding. Hormone related post-menopausal bleeding ("PMB") is usually controlled by manipulation and alteration of the hormone regimen. Certain hyperplasias may require extra progesterone-like supplementation in order to reverse this process. Polyps or fibroids protruding into the uterine cavity can removed with the hysteroscope, and the lining may then be sealed with electrical energy ("endometrial ablation") to minimize any further PMB.
DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS
The Chair of the Committee was selected by the Regional Chief of Obstetrics and Gynecology for Kaiser Permanente Southern California. The remaining members of the Committee were selected by the chairs of each of the 12 medical centers.
Face to face meetings were planned monthly with ad hoc face to face or teleconference-based meetings held as necessary.
After an introductory discussion on the general and Southern California Permanente Medical Group (SCPMG)-specific issues involved in the general problem of post menopausal bleeding (PMB), the committee met as a whole to review methods of guideline development, agree on terms for evidence classification, and to come to consensus on the scope of the guideline(s) to be developed. The Working Group Chair prepared a shell document to aid the guideline development process.
A subgroup of three individuals was charged with leading the investigation and developing draft documents for meetings of the whole group. Drafts were electronically distributed to the whole group and monthly face to face meetings were used to obtain feedback from each of the members of the committee.
The recommendations were created and classified according to the strength of the evidence, classified according to the system used by the American College of Obstetricians and Gynecologists (see rating scheme below).
from : guideline.gov , obgyn
