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Post Menopausal Bleeding




So, there can be a variety of things that we will go over a little bit later as to what can cause post menopausal bleeding.  But, for her, she only has one month of spotting daily, no pelvic pain, no family history of cancer.  So, when we went and did the physical exam, we found that she had a BMI of 30.  Now, why is this important to know that she has a BMI of 30?  Well this puts her in the obese category, and patients who are obese have a higher incidence of endometrial cancer.  The reason being is that these patients have increased unopposed estrogen in their system and this increased estrogen is what predisposes patients to endometrial cancer.  So, its very important to know the BMI of this patient.  There are also other things that can contribute to endometrial cancer, but for the physical exam, she had a BMI of 30.  Now, we have to do a vaginal exam; one to see if there is any blood that is visible in the vaginal canal and two, to see if she has any lesions or lacerations that can actually be the cause of bleeding.  Just because we stated earlier that this patient has post menopausal bleeding, doesn’t necessarily mean that we have endometrial cancer.  When we do a vaginal exam, you need to make sure that there aren’t any lacerations or any cuts noted inside the vaginal canal.  Things like candidiasis can cause lacerations and things like cervical polyps will be readily visible on physical exam.  So, those are things you can exclude as far as lower genital track etiologies with physical exam.  No, she did not demonstrate any lesions, lacerations, or visible polyps that could contribute to post menopausal bleeding.  So, what do we do next? Well, there are three things.

For your boards, you need to do an endometrial biopsy.  Now, in clinical practice things are a little bit different.  Now, she hasn’t had a pap smear in about two years.  Current pap smear guidelines suggest screening every three years so long as the prior pap smear was normal and in patients over the age of 30, you can actually extend that to every five years as long as you do concurrent HPV testing.  But, anyway its been two years, she has a new symptom, lets just go ahead and do a pap smear.  Only one percent of patients who have post menopausal bleeding are going to have cervical cancer, but its very easy to do, its a very simple screening test.   A pap smear is not diagnostic by any means, its a screening test for cancer, cervical cancer.  Transvaginal ultrasound is something that I sent her out to do, and the reason being is, we want to look at the thickness, right?  So, an endometrial stripe, or an endometrial thickness under 4mm really reduces that risk of endometrial cancer.  Anything over 4mm in post menopausal women needs further evaluation.  Now, is it possible to have endometrial cancer with a thickness less than 4mm?  Of course, but the chances are really really low.  The other thing is, depending on the ultrasound results, depending on the pap smear results, I will probably refer for endometrial biopsy.  Now, what would stop me from referring this patient from getting an endometrial biopsy?  Well, if she has fibroids right?  So, if we do an ultrasound and this patient comes back with fibroids, thats more than likely the cause of her bleeding.  If you find endocervical polyps, or find uterine polyps, also reasons of post menopausal bleeding.  That can readily be picked up on ultrasound.  So, any woman who has post menopausal bleeding has endometrial cancer until proven otherwise, but the vast majority of patients are not going to have endometrial cancer.  They are going to have other etiologies.  Thats why transvaginal ultrasound can be very helpful.

As far as the differential goes, by far the most common cause of post menopausal bleeding is going to be atrophy of the vaginal mucosa, and this again, can be readily visible on physical exam.  Second is going to be polyps, fibroids, followed by endometrial hyperplasia and endometrial cancer.  As I stated earlier, only about ten percent of patients with post menopausal bleeding are going to have cancer.  Endometrial hyperplasia is a diagnosis based on biopsy, so you need to have that biopsy to either make the diagnosis of hyperplasia or cancer.  Atrophy of the vaginal mucosa is something that can be picked up by physical exam. Polyps and fibroids are something that can be picked up with transvaginal ultrasound, which is why all of these are very important to do.  So, for your boards, and for clinical practice, the main thing that I want to reiterate here is that any woman that presents with post menopausal bleeding has endometrial cancer until proven otherwise.  However, 90% of the etiologies are going to be things other than endometrial cancer.

So, that is our case presentation for today.  This was very brief and I wanted to hit one point only, and that is that you need to do the work up for endometrial cancer and in clinical practice it is acceptable to do a transvaginal ultrasound to look for endometrial thickness, and you don’t necessarily need to jump to a biopsy right away.  But, for your boards, everyone needs a biopsy because that is what they want you to know.  They want you to know that you are going to rule out endometrial cancer.  Alright guys thanks so much for joining me today.  Hope you have a great day!