MANAGEMENT OF POSTMENOPAUSAL WOMEN WITH UTERINE BLEEDING IN PRIMARY CARE CARE 1 Silva ,
2 Trigo ,
1 Aguiar
Eva Sara Lisa 1 Centro de Saúde de Angra do Heroísmo, 2Centro de Saúde de Ponta Delgada
INTRODUCTION Postmenopausal bleeding refers to any uterine bleeding in menopausal women. It is one of the most common health problems, leading many women to look for the family doctor. Any postmenopausal bleeding should be considered abnormal and has to be carefully evaluated in order to diagnose the cause. It is very important to know the main causes of an uterine bleeding to provide the correct management, since it occurs in 4 to 11% of all postmenopausal women.
OBJECTIVES
METHODS
The goal of this review is to create a flowchart to manage postmenopausal uterine bleeding in primary care.
Classic review, based on english and portuguese scientific articles published over the last 10 years in Medline, UpToDate® and Medscape® databases, using the MESH terms: postmenopausal uterine bleeding and family physician.
RESULTS TYPES AND FREQUENCY OF HISTOPATHOLOGICAL DIAGNOSIS 1% 1% 7%
Atrophy 10%
Polyps Endometrial cancer
10%
Endometrial Hyperplasia 59%
Hormonotherapy Cervical cancer
12%
Other
COMMON CAUSES OF POSTMENOPAUSAL UTERINE BLEEDING GINECOLOGYCAL Hormonal effect Hyperplasia Vaginal / endometrial atrophy Endometrial cancer Vaginal / vulvar cancer Trauma Vaginitis / cervicitis Polyps NONGYNECOLOGICAL Coagulation disorders Diseases in adjacent organs (urinary and gastrointestinal tracts)
CLINICAL HISTORY Hormonotherapy Bleeding pattern Sexual activity Family history Coagulation disorders Other symptoms Risk factors endometrial cancer
Duration? Trauma? Quantity? Evolution? Postcoital? Dyspareunia? Breast, colon and endometrial cancer Medication, Hematological diseases Pain? Fever? Leucorrhoea? Changes in bladder or bowel function? Age (60-70 years) Diabetes Mellitus Hypertension Obesity Nulliparity Lynch II syndrome Tamoxifen Polycystic ovary syndrome
HEMOGRAMA AND COAGULATION STUDY CERVICAL CYTOLOGY TRANSVAGINAL ULTRASOUND
< 3mm
PHYSICAL EXAMINATION BMI Abdominal palpation Mass? Pain? Gynecological Signs of vaginal atrophy examination Lesions, lacerations, foreign bodies, polyps Size, contour, tenderness of the uterus Urethra and anus Site of bleeding inspection
ENDOMETRIAL THICKNESS
Wait and watch
≥3mm Endometrial heterogeneity Endometrial not adequately visualized
Persistent bleeding
REFER TO GYNECOLOGIST
CONCLUSION All uterine bleeding in a menopausal woman should be investigated. Endometrial atrophy and endometrial polys are the most common causes of postmenopausal bleeding, however it is important to exclude malignancy because endometrial carcinoma is the cause of about 10% of patients. The family physician is often the first contact of women with these complaints, so It is crucial to provide the best initial approach in primary care. Here upon, the construction of this flowchart is critical to the clinical practice. BIBLIOGRAPHY:Goodman A. Postmenopausal bleeding. In: UpToDate, Barbieri RL (Ed), Waltham, MA, 2013; Mounsey AL. Postmenopausal Bleeding: evaluation and management. Clinics in family practice, 2002; 4(1);. Ramos LA, Santos L and Fatela A. Metrorragia pós-menopausa. Rev Port Clin Geral, 2003; 19:573-80; Burbos N, Musonda P, Giarenis, I, Shiner AM, Giamougiannis P, Morris E, Nieto, JJ. Age-related differential diagnosis of vaginal bleeding in postmenopausal women_ a series of 3047 symptomatic postmenopausal women. Menopause International 2010; 16:5-8; Hanegem N, Breijer MV, Khan, KS, Clarck TJ, Burger MPM, Mol BWJ, Timmermans A. Diagnostic evaluation of the endometrium in postmenopausal bleeding: An evidence-based approach. Maturitas, 2011; 68: 155-164.Dowdy SC, Mariani A, Lurain jJR. Uterine Cancer. In Berek & Novak’s Gynecology, (Berek, JS ed) 15th edition, Lippincott Williams &Wilkins. 2012; Sociedade Portuguesa de Ginecologia et al. Cancro Ginecológico – consensos nacionais 2013. Coimbra, 2013.