Menopause and Post-menopausal bleeding

Part One: Menopause

A 52 year old Sudanese woman presents with hot-flushes and night sweats. She has had no period for 14 months.

Take a history from her, eliciting other symptoms relating to the climacteric.

  • Vaginal dryness
  • Changes to the vulva
  • Urinary symptoms i.e. frequency and nocturia
  • Anxiety &depression (central symptoms)

What treatment would you suggest to control this woman’s symptoms?

  • Replace oestrogen
  • If she still has a uterus: oestrogen is given in combination with progestogen to prevent unopposed oestrogen stimulation to the endometrium that could give rise to endometrial hyperplasia, atypia or neoplasia.

Describe the various ways oestrogen/ progestogen replacement can be given.

  • HRT may be given cyclically or continuously – continuous more common

Routes of administration:

oestrogen / progestogen
Tablet
Patch
Gel
Implant
Intranasal
Vaginal treatments / Tablet
Patch
Vaginal progesterone gel

What are the common side effects of HRT?

Oestrogen-related:

  • Breast tenderness
  • Nausea
  • Headaches

Progestogen-related:

  • Leg cramps
  • PMT-type symptoms ie irritability, bloating, headaches
  • Irregular bleeding

What is withdrawal bleeding?

  • If steroids are given sequentially, most women experience withdrawal ‘menstrual’ bleeding
  • 10% women will have excessive losses- up to 80mls
  • Can be limited by giving drugs in continuous combined fashion
  • Is a major constraint in compliance to HRT

What are the potential adverse effects of HRT?

  • Increased predisposition to breast cancer
  • Risks are not large and benefits outweigh potential drawbacks
  • Women taking HRT to be monitored via regular breast assessment i.e. mammography
  • Steroids prescribed for women with strong family history of breast cancer

Contraindications for HRT:

Women who develop acute thromboembolic event

Describe the changes to the external genitalia postmenopausally.

  • Skin becomes atrophic
  • Labia diminish in size
  • Sparsity of pubic hair

What are the medium and long-term consequences of hypo-oestrogenism?

Main:

(a) Loss of bone mineral

(b) CVS disease

What is the significance of osteoporosis in relation to PM women?

  • Important cause of morbidity and mortality in PM women
  • Loss of calcified trabecular bone; increases risk of fractures

What are the most common problems encountered in relation to osteoporosis?

  • Vertebral crush fractures
  • Colles fractures
  • Fractures of neck of femur

Explain how the build of the women would be relevant to this.

  • Slightly built women most at risk
  • Obese women are protected because the conversion of androgens to esterone in peripheral adipose tissue gives some protection.

How does oestrogen confer protection against CVS during the premenopausal years?

Suggested that it is due to the action of oestrogens on blood lipids and vascular endothelium/smooth muscle.

Part two: postmenopausal bleeding

(i) A loud Iraqi 55 year old woman presents with a history of vaginal bleeding on two occasions over the past three months.

Take a brief history and examination and discuss the investigations that would follow.

Questions to elucidate salient points on history:

  • Is she truly menopausal? True menopause: woman of climacteric age who has had no menses for 6 months or more.
  • When did the bleeding occur?
  • How heavy was the bleeding?
  • Was it fresh or old blood? (Heavy fresh bleeding that recurs or is prolonged points to more sinister aetiology.)
  • How long did the bleeding last for?
  • Were there any precipitating factors?
  • Are you on HRT?
  • Are you on any drugs? (i.i. tamoxifen and warfarin are associated with abnormal uterine bleeding)
  • When was your last smear and your cervical screening history (bleeding could be cervical in origin)
  • Risk factors associated with increased risk of endometrial carcinoma: nulliparity, obesity, diabetes, PCOS. (All associated with chronic anovulation and unopposed oestrogen stimulation of the endometrium.)

What are the potential causes of post menopausal bleeding?

  • Carcinomas of genital tract:-endometrial, cervical, vaginal, urethral, vulval
  • Vulval causes:-excoriation due to itch and ulceration (may be due to Bechets/herpes)
  • Urethral caruncle
  • Vaginal causes:-atrophic vaginitis

-vaginal tears

  • Cervical causes:- Polyps

-chronic inflammation

  • Intrauterine causes:-Endometrial polyps

-Endometrial hyperplasia

Examination should include:

  • Abdominal palpation – to exclude mass arising from pelvis
  • Full pelvic examination
  • Inspection of vulva, vagina and cervix for lesions
  • Cervical smear-taken if appearance suspicious or routine screening is due
  • Bimanual examination to -reveal size, position, motility of uterus.

- presence of adnexal mass

Investigations:

  • Transvaginal ultrasonography of uterus – looks directly at endometrium.
  • Uniformly thickened endometrium: indicates malignancy/ hyperplasia
  • Localised thickening: polyp
  • Endometrial biopsy: improves accuracy of diagnosis
  • Hysteroscopy and directed biopsy: indicated if appearance of endometrium on US is suspicious.

(ii) The results of the loud Iraqi 55 year old woman come back. Transvaginal ultrasonography shows the endometrium to be 12mm thick and you proceed to hysteroscopy and directed biopsy. Histopathology reveals simple hyperplasia with no atypia. How would you manage this patient? Would you treat her?

  • If left untreated: simple hyperplasia may become atypical thus precursor to endometrial carcinoma.
  • Progestogen- given in form of continuous oral therapy, will encourage reversion of simple hyperplasia to normal.
  • Alternatively: insert progestogen-releasing intrauterine system.
  • Follow-up: endometrial biopsy after a few months.