Professional Documents
Culture Documents
Nanette Santoro MD
Matthew Lederman MD
Basics
Description
MT:
o Previously referred to as perimenopause
o
Age-Related Factors
Median age of onset MT = 47.5 years
Median length of MT = 4 years
Epidemiology
AUB accounts for up to 20% of office visits and frequently seen in MT.
<10% of cases of postmenopausal bleeding are due to endometrial cancer.
Risk Factors
Fibroids
Genetics
Primary determining factor influencing age of menopause
Pathophysiology
MT:
o Shorter menstrual cycles 2o shorter follicular-phase in ovulatory cycles
alternating with variable-length anovulatory cycles:
Postmenopausal AUB:
o
Diagnosis
Signs and Symptoms
History
Important to distinguish between a normal MT and a pathologic cause.
Changes in bleeding patterns:
o
Postcoital bleeding
Vaginal atrophy/pruritus/dyspareunia
Review of Systems
Hot flashes:
o Prevalence of 57% in late perimenopause and 49% in early menopause
Sleep disturbances
Symptoms of anemia
Urethritis/Cystitis
Physical Exam
Vital signs:
o Tachycardia or postural hypotension (if suspicious of anemia)
Size of uterus
Vaginal atrophy
Rectal exam
Tests
Pap smear
Labs
CBC
TFTs
+/- HCG
Imaging
Clinician comfort and skill will direct workup.
Menopausal transition AUB; use Goldstein's clinical algorithm:
o
Postmenopausal bleeding:
o
Differential Diagnosis
Infection
Cervicitis/Chronic endometritis
Hematologic
Unlikely: Acquired von Willebrand disease
Metabolic/Endocrine
Unlikely postmenopause unless hormone treatment used
MT:
o
Tumor/Malignancy
Endometrial hyperplasia:
o Simple vs. complex
Endometrial carcinoma:
o
+/- atypia
Cervical carcinoma
P.15
Trauma
Unlikely in this age group; rule out with history
Drugs
Hormonal therapy:
o Breakthrough bleeding usually resolves after 612 months in
postmenopausal women:
Tamoxifen:
o
Other/Miscellaneous
Pregnancy
Anatomic:
o
Uterine fibroids
Cervical/Endometrial polyps
Adenomyosis (MT)
Atrophy:
Management
Treatment depends on specific diagnosis
Medication (Drugs)
DUB: Goal is to restore the stabilizing effect of luteal progesterone and
prevent hyperplasia:
o Low dose monophasic OCPs:
Levonorgestrel-IUD (Mirena):
Provides contraception
NSAIDs
Endometrial hyperplasia:
o
Atrophic vaginitis:
o
Surgery
Anovulation:
o Endometrial ablation:
Uterine fibroids:
Hysterectomy
Followup
Depends on specific diagnosis
Hysteroscopy may be needed for persistent bleeding even if workup is
negative.
Disposition
Issues for Referral
May require referral to gynecological oncologist if carcinoma present or to
reproductive endocrinologist for management of menopause
Prognosis
Depends on specific diagnosis
DUB eventually remits with menopause.
Endometrial polyps:
o
Endometrial hyperplasia:
o
Progression to carcinoma:
Patient Monitoring
Depends on specific diagnosis and treatment
Yearly office visit recommended unless change in bleeding pattern
Bibliography
Gold EB, et al. Relation of demographic and lifestyle factors to symptoms in a multiracial/ethnic population of women 4055 years of age. Am J Epidemiol.
2002;152:463473.