A woman’s life is divided into seven stages, the physiological characteristics of each stage are different, especially the late menopause health care is particularly important, under the influence of a variety of health trends, I think we know from diet, exercise to maintain health is as good as it is, this article is mainly to talk to you about postmenopausal bleeding some things, but also promised to patients Nana do science, recently she asked about her mother after menopause appeared vaginal bleeding especially I hope this knowledge can guide people who need it.
I. What exactly causes postmenopausal bleeding?
At the age of about 50-55 years old when menstruation is completely absent for more than a year we are considered to be in the late stage of menopause. The most common sites of postmenopausal vaginal bleeding are the vulva, vagina and uterus. The most common of these is uterine bleeding, and it is also the most complicated. The more common benign diseases include senile vaginitis, endometritis, cervical polyp, endometrial polyp, uterine stroke syndrome, postmenopausal intrauterine device left in place for a long time, etc. The more common malignant diseases include endometrial cancer, cervical cancer, ovarian cancer, fallopian tube cancer, etc. Among them, endometrial cancer accounts for about 80% of the whole postmenopausal bleeding.
Finding out the cause of postmenopausal vaginal bleeding in a timely manner is the key to properly manage this type of disease. Vaginal bleeding is not an isolated symptom, but an external manifestation of a disease, or even multiple diseases. Understanding the disease by its symptoms and recognizing it by its external manifestations is possible in many diseases.
In postmenopausal benign disease vaginal bleeding, the systemic symptoms are usually not obvious, the bleeding is not too severe, malignant-like body rarely occurs, and there is no obvious abnormality in the leucorrhea unless it is accompanied by bacterial infection to have an abnormal odor. Senile vaginitis bleeding is low, often spotting blood, and is accompanied by itching and burning sensation of vulva, or discomfort of small abdominal cramps, sometimes trichomonas and mycobacteria can be detected, but the uterus is normal in size, shape and texture. Endometritis has regular vaginal bleeding, about half of the patients have pain or feel cramping in the lower abdomen, increased leucorrhea, and if it is acute it is also accompanied by fever, no obvious abnormalities in gynecological examination, and obvious results of antibiotic treatment. If it is a refractory uterine cavity pus can be considered to remove the uterus, we have done a few cases with good results. Cervical polyp is also one of the common causes of bleeding, this disease bleeding mostly occurs during sex, gynecological examination or ultrasound can be found on the cervical polyps, and malignant tumors are different, when suspicious biopsy can be performed. Uterine stroke syndrome, obstructive bleeding is very much like menstrual flow, bleeding volume is slightly larger, hypothermia and increased leukocytes can occur if complicated by infection, all of this disease have symptoms of arteriosclerosis and abnormal cardiac function performance, often cough, dyspnea, panic, enlarged heart, swelling of lower limbs, enlarged liver and a series of symptoms of heart failure, uterus size is normal, pelvic cavity without mass, diagnostic scraping confirmed as endometrial necrotizing hemorrhage.
Malignant disease occurs after menopause, also with vaginal bleeding. Most of the bleeding from this type of disease is complicated by a series of symptoms of malignant disease, poor health, wasting, weakness, low fever, unpleasant smell of bloody vaginal discharge, and no significant effect of antibiotic treatment. Endometrial cancer, mostly has irregular vaginal bleeding, or bleeding with overflow, the liquid is yellow watery, the smell is especially unpleasant, lower abdominal pain, abdominal mass, abnormalities can be detected by ultrasound and gynecological examination, and the disease often has a history of diabetes, hypertension, obesity (the first three are the triad of endometrial cancer), multiple births, unborn children, infertility, etc. Cervical cancer, too, has irregular vaginal bleeding, bloody discharge, abdominal pain with a feeling of falling, and frequent, urgent, painful urination or hematuria in advanced stages, and abnormal cervix can be detected by ultrasound or gynecological examination. Ovarian cancer is also a common malignant tumor. The causes of this disease are complex and varied, but all of them have symptoms such as lower abdominal discomfort, abdominal mass, abdominal pain, vaginal bleeding, etc. The diagnosis can be confirmed by gynecological examination, relevant instruments and laboratory tests. Fallopian tube cancer, which is an uncommon malignant tumor, also has symptoms similar to those of the above diseases, only that they are not obvious.
Post-menopausal bleeding caused by endogenous or exogenous estrogen. After menopause, due to the gradual decline of ovarian physiological function, the estrogen level decreases and cannot support the effective growth of endometrium, but the endometrium of postmenopausal women still responds to estrogen. After menopause, both the interstitial ovaries and the adrenal cortex can secrete androgens, which are converted into estrone. Therefore, fluctuations in estrogen can cause vaginal bleeding. Similarly, bleeding can also occur when the endometrium is exposed to the action of foreign estrogens.
The key to this disease is early detection and treatment. Once vaginal bleeding occurs, it should not be taken lightly and should be diagnosed and treated in a timely manner. During vaginal bleeding, it is important to pay attention to personal hygiene and prevent infection, especially when the leukorrhea already smells.
Second, what kind of examination is needed for postmenopausal bleeding?
The cause can be figured out through detailed history taking, gynecological examination, cervical cytology and histological examination, and progressively through ultrasound and hysteroscopy.
Laboratory tests
1.Hysteroscopy The diagnostic accuracy of fiberoptic hysteroscopy is higher than that of TVS, which can miss local hyperplastic lesions and adenocarcinoma, and even the endometrium detected by TVS and SHSG needs to be biopsied directly under hysteroscopy, so fiberoptic hysteroscopy is better than vaginal ultrasound in examining lesions of perimenopausal and postmenopausal uterine bleeding.
There are four reasons for this.
First, the thickness of the endometrium in the non-hormonally treated bilayer is <4 mm as the cut point, and the rate of missing abnormal endometrium by vaginal ultrasound is 5.5%, while the accuracy of localized biopsy under fiberoptic hysteroscopy is higher than 94%;
Secondly, endometrial hyperplasia and endometrial adenocarcinoma are focal in the initial stage, which can be easily missed by vaginal ultrasound, while fiberoptic hysteroscopy can detect and take biopsy under direct vision;
Thirdly, sometimes more than two biopsies are needed to determine the extent of the tumor or lesion, and fiberoptic hysteroscopy can detect and biopsy multiple points under direct vision;
Fourth, abnormal vaginal ultrasound findings need pathological confirmation, and fiberoptic hysteroscopy can be used for direct biopsy.
2, TVS is a non-invasive examination method commonly used to initially screen for causes of postmenopausal uterine bleeding, Karlsson study PMB in which TVS did not see any abnormalities, endometrium ≤4nnn, while official hysteroscopy found 1 case of small endometrial polyp; 39 cases of endometrium >4mm, TVS suggested endometrial abnormalities, hysteroscopy only confirmed 35 cases, 4 false positives; 9 cases of endometrium ≥8mm, hysteroscopy showed 8 cases 8mm, hysteroscopy showed 8 cases with endometrial polyps and 1 case with endometrial polyp or submucosal myoma. With pathological findings as the final diagnosis, the sensitivity, specificity, positive predictive value and negative predictive value of TVS were 100%, 75%,, 90% and 100%, respectively, and the corresponding hysteroscopy was 97%, 88%, 94% and 93%. The results of TVS and hysteroscopic tissue biopsy were found to be >90% consistent with surgery, with a sensitivity of 94% and specificity of 96%, and no endometrial hyperplasia or cancer was missed. TVS can be used as the first step in the routine evaluation of PMB, and hysteroscopy must be applied when the ultrasound image is abnormal or inconclusive, or when the ultrasound image is normal and the patient continues to have symptoms, along with further microscopic biopsy to exclude or show pathology.
Third, how should postmenopausal bleeding be treated?
The first choice is hysteroscopy or segmental scraping. Hysteroscopy can be done as much as possible because some small lesions may be missed during scraping. In case of polyps, polypectomy can be performed during hysteroscopy, while in case of cancer, total uterus plus bilateral adnexa plus pelvic lymphatic drainage is required. Post-operatively, the need for radiotherapy and hormone therapy is determined by pathology and estrogen and progesterone receptors. Yesterday’s surgery day included a hysteroscopic finding of cauliflower-like growths in a postmenopausal patient with thick endometrium, like a poisonous mushroom…too pretty and too sultry is a curse? Add a digression to lighten the mood.
In conclusion, postmenopausal bleeding is not necessarily cancer, but one must do an ultrasound for early detection of cancer by hysteroscopy. The prognosis of endometrial cancer is still very good except for a few special types, and it is a relatively mild cancer among the three major gynecological tumors.