1. Postmenopausal bleeding
Aymen zemmal (10110068)

2. contents
• SOEPEL.
• Brief illustrate of terms related to menopause.
• Menopause: age, pathophysiology, hormone
level, anatomical changes, menopausal
symptoms and treatment.
• Postmenopausal bleeding: etiology, clinical
features, diagnosis and investigations.
• Management.

3. SOEPEL
• Wadha is 54 years old saudi from oneiza is house wife
and mother of 2 sons and 8 daughters.
• Chief complain: vaginal bleeding, abdominal pain and
diarrhea.
• History of presenting illness: slight vaginal bleeding since
1 day, lower sudden moderate progressive abdominal
pain not radiated since 1 day the diarrhea frequency is
more than 10 time not associated with blood or mucus
since yestreday.
• Past history:
medical: arthritis and right hand swelling.
surgical: cessarian section and hysterectomy since months
due to 2 kg fibroid uterus.
OBG: menorrhagia.
medications:

4. • Family history: no
• Social history: healthy house wife and her husband is
smoker.
• Review of systems:
GI: slight neasea, no fever, lower abdominal
pain diarrhea.no weight loss and no vomit.
OBG:
menstrual history: menache 13
menopause: no just after hysterectomy.
LMP:2 months.
cycle length and frequency:28/6
postmenopausl bleeding: slight vaginal bleeding.
postcoital bleeding.

5. • Discharge: yellowish slight not iching and no resh since 2
days.
• Abdominal pain:
bowel problems here diahrea is due to
unheaten mild.
dyspareunia
prolapse
Urinary symptoms:
Obstetric history: 2 sons and 8 daughters got normal vaginal
delivery except last one got cessarian section.
contraceptions:
Sex relationships:
Infections:

6. SOEPEL
• Object:
GE: HR is 80. coulour, respiration is 18 term: 37.
BP is 70/139. no alarm signs such
abdominal examination especially palpation
will reveal if there is a tumor.
Gynae examination: speculum and bimanual
examinations.

7. SOEPEL
• Evaluation: DD:
vulva: vulvitis, benign and malignant lesions and
cancer.
vaginal tumor: benign or malignant or foreign body.

8. SOEPEL
• Plan: investigations and diagnostic techniques.
CBC
ultrasound
laparscopy if ultrasound pick a pelvic tumor.
biobsy.
Learning goals:
postmenopausal bleeding.

9. Important terms related to menopause
• Perimenopause: is period of 3-4 years before
menopause and followed by a year of amenorrhea.
• Menopause: timed of cessation of ovarian function
resulting in permenant amenorrhea. It take 12
months to confirm that it is menopause.
• Late menopause: menstruation continues beyond
52 year sometimes it is normal due to healthy
habits, and due to developed ovarian cancer or
fibroid.
• Postmenopausal bleeding: normaly after 1 year of
amenorhea vaginal bleeding is occuring.

12. menopause
• Occuring between 45-50 years average is 47
years.
• It is difficult to see women after age of 50
menstruate well this delayed menopause
could be due to good nutrition.
• Menopausal age differences is not related to
menarche race, socioeconomic status, number
of pregnancies and lactation or usage of oral
contraceptives. ( who agree?)

13. pathophysiology
• Ovarian activity decline, initially ovulation fails so, no
corpus luteum and no progesterone secreted in ovary.
So, the premenopausal cycles are often anovulatory
and irregular.
• later, grafian follicle fails to develop estrogenic activity
reduction and endometrial atrophy leads to
amenorrhea.
• Homones levels:
50% reduction in estrogenic production.
66% reduction in estrogen at menopause.
E2, oestrone, FSH, androgens, testesterone, LH and
androsternedione.
:

14. Risk factors for menopause related diseases
•
•
•
•
•
•
Early menopause.
Surgical menopause.
Chemotherapy especially alkalytic agents.
Smoking, caffeine and alcohol.
Family history of menopausal diseases.
Drugs such GnRH, heparin, corticosteiroids, and
clomphene(anti-estrogen)when given over prolonged
period( anti estrgenic) can lead to estrogenic
deficiency.

15. • Atrophy and regression of genital organs.
• Menopausal symptoms: sudden
cessation, gradual decrease of menses until to
stop and gradual of length of cycle.
• 60 to 70% without symptoms.
• Hot flushes: waves of vasodilation affect face
and neck last for 2-5 minutes each followed by
severe sweating.
• Irritability an lack of concentration.
• Paresthesia.

16. • Libido changes.
• Dysuria without infection.
• Lately:
arthritis, osteoporosis, cardiovascular, stroke, s
kin changes, prolapse of genital tract.
• Treatment
HRT which protect against
osteoporosis, cardiovascular
symptoms, stroke, alzheimer disease and colonic
cancer.

17. Postmenopausal bleeding
• Normally 1 year of amenorrhea then vaginal
bleeding occuring after 6 months of amenorrhea.
• Etiology:
vulva: trauma, vulvitis, benign and malignant
lesions.
Cervix: cervical
erosion, cervicitis, polyp, decubitus, ulcer in
prolapse and malignancy.
Uterus: senile endometriosis, tubercular
endometritis

18. •
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•
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Ovary:
Fallopian tube malignancy.
Hypertension or anemia.
Urinary tract
Bowel problems

19. Clinical features
• Abdominal pain.
• Foul smelling discharge noticed in malignant
tumors.
• Bleeding painless.
• Urinary and rectal symptoms.

20. Diagnosis and investigation
• GE: vital signs and alarm signs.
• Abdominal and gynacological examination.
• Investigations:
CBC, ultrasound, hysteroscopy, laparscopy and
biobsy.

21. Management and treatment
• Treat the cause first.
• Patient should be kept under observation
(warding).