Hi. This is Dr. Jane Limmer. We’re going to be discussing post-menopausal bleeding in this presentation. Learning objectives for this presentation are as follows– to review benign and malignant causes of post-menopausal bleeding, to understand the diagnostic evaluation of post-menopausal bleeding, and to review treatment strategies depending on the diagnosis. Post-menopausal bleeding is defined as bleeding from the genital tract in a woman who has undergone menopause and is not on hormone replacement or as irregular bleeding from the genital tract in a post-menopausal woman who is on hormone replacement. The complaint of such bleeding accounts for 5% of all office visits to gynecologists. There is a wide range of possible etiologies to be considered, but the patient must always be evaluated for endometrial cancer. While keeping endometrial cancer at the top of the list, there are other possibilities that should be considered in the differential diagnosis. We can start to understand these diagnoses by separating them into gynecologic and non-gynecologic causes. Some patients will have bleeding from the rectum or urethra that they may perceive as vaginal bleeding. It is crucial to distinguish the source of bleeding with a thorough history and physical. If the bleeding is confirmed to be vaginal in origin, gynecologic causes of post-menopausal believing can be further subdivided into intra and extra uterine and in to benign and malignant. We will discuss uterine causes further later in this presentation. The most common cause of post-menopausal bleeding overall is benign vaginal atrophy. Atrophy is easily recognized on physical exam by the presence of a thin, pale, vaginal epithelium coupled with narrowing of the introitus. Patients with this condition will often also complain of dyspareunia and possibly post-coital bleeding. In addition to endometrial cancer, other malignancies of the gynecologic tract may cause post-menopausal bleeding and should be considered if the remainder of the workup is negative. These include fallopian tube cancer, ovarian and cervical cancer, and vaginal and vulvar cancer. There are multiple types of intrauterine pathology, both benign and malignant, that can cause post-menopausal bleeding. The most common– accounting for 45% of uterine post-menopausal bleeding– is endometrial atrophy. Other abnormalities of the uterine lining such as polyps and submucosal fibroids are also common causes. Endometrial hyperplasia, which is considered a precursor lesion to endometrial carcinoma, accounts for 15% of all uterine post-menopausal bleeding. And carcinoma itself accounts for 10%. When a patient presents with a complaint of post-menopausal bleeding, she should undergo careful evaluation starting, of course, with a history and physical. If the patient describes heavy bleeding, checking a comprehensive blood count may be indicated. If physical exam reveals a visible lesion such as vaginal atrophy or cervical polyp, this should be biopsied and/or treated immediately. If the patient has an enlarged uterus on bimanual exam– which may indicate the presence of uterine fibroids– a pelvic ultrasound should be obtained. If the patient’s exam is completely normal and the patient is not on hormone replacement, the first step should be endometrial biopsy and/or transvaginal ultrasound to evaluate the uterine lining. Which of these tests to perform first can be controversial and will be discussed more in the next slide. Results of the biopsy and ultrasound will direct further workup and management. A woman having persistent post-menopausal bleeding with a normal endometrial biopsy warrants further workup, starting with a pelvic ultrasound if this has not already been done. A larger sample of the endometrium can be obtained with hysteroscopy and focused biopsy and with dilation and curettage. One of these procedures should be considered to definitively rule out endometrial cancer in this setting. Again, the initial test to evaluate for endometrial cancer may be either a biopsy or an ultrasound. Endometrial biopsy is performed with a small plastic suction pipelle. Though such biopsies provide only a small amount of tissue, the sensitivity is 85% to 95%, and the specificity is 98%. Patients at high risk for an endometrial cancer such as morbidly obese women and women with a history of anovulatory bleeding who have negative biopsies and persistent bleeding should be further evaluated. If a patient is at low risk for endometrial cancer, pelvic ultrasound may be performed first to measure the thickness of the endometrium. If the endometrial thickness is less than four millimeters, biopsy would typically not be performed. The treatment of post-menopausal bleeding is, of course, dependent on the cause. Vaginal atrophy should be treated with topical estrogens applied directly to the vagina or systemic estrogen. Endometrial atrophy is similarly treated with a short course of systemic estrogen. If polyps or fibroids are found, surgical removal should resolve the bleeding. Some patients will elect for minor procedures such as hysteroscopic polypectomies or myomectomies while others will wish to pursue definitive surgery with hysterectomy. Endometrial hyperplasia can be medically managed in order to prevent progression to endometrial cancer. Obese women should be counseled on the importance of weight loss as excess adipose tissue creates systemic estrogen that acts as a stimulus for endometrial growth. Medical treatment for hyperplasia includes systemic progesterones in a Marena IUD, which releases local progesterone and thins the uterine lining. If endometrial cancer is found on biopsy, hysterectomy is definitive treatment. However, there may be patients who are not good candidates for surgery who can be treated with the medications listed above or radiation. In summary, there are many causes of post-menopausal bleeding. But one must always suspect endometrial cancer. The workup of post-menopausal bleeding is focused on ultrasound and endometrial biopsy. And the treatment depends on the cause but often involves hormonal management or surgery.