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Dr Mohammed Abdalla Egypt Domiat general hospital • is the permanent cessation of menstruation resulting from loss of ovarian follicular activity • It can only be determined after 12

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									   Dr. Mohammed Abdalla
Egypt, Domiat general hospital
• is the permanent cessation of
  menstruation resulting from loss of
  ovarian follicular activity.
• It can only be determined after 12
  months' spontaneous amenorrhoea.
• Mean age is 51 years.
• is the period of time in which the ovaries
  are beginning to fail, where endocrine,
  biological, and clinical changes are seen.
  It ends with the final menstrual period.
• Length of the transition is approximately
  4 years
is the time period over which the ovaries
  are failing (when symptoms begin) up
  until the cessation of menstruation, and
  ends 12 months after the final
  menstrual period.
is the time after the menopause, that is, after the
   permanent cessation of menstruation. It can only
   be determined after 12 months of spontaneous
   amenorrhoea.
 In practice this definition is difficult to apply,
   especially in women who have started hormone
   replacement therapy (HRT) in the perimenopause.
   It has been estimated that by the age of 54 years,
   80% of women are postmenopausal [McKinlay et
   al, 1992; DTB, 1996].
occurs after bilateral oophorectomy with or
  without hysterectomy.
Premature menopause may also be
  radiation- or chemotherapy-induced, or
  occur after hysterectomy with ovarian
  conservation.
• A premature menopause is one that
  occurs before the age of 40 years.
• Primary premature menopause may
  occur at any age and present as
  amenorrhoea. Not all women have acute
  symptoms. FSH levels are elevated.
  Spontaneous fertility may recur.
 It is possible to discontinue the HRT or COC pill and
  measure the follicle-stimulating hormone (FSH) level
  after 6-8 weeks. The POP does not affect FSH levels
  and so does not need to be stopped for FSH testing
  [Gebbie, 1998].
 An FSH value over 30 IU/L is in the postmenopausal
  range, but should be repeated 4-8 weeks later to
  confirm this.
 Even if the FSH levels are in the postmenopausal
  range, this may not reliably indicate infertility, and
  contraception should be continued for a further 1 year
  if the woman is over 50 years old, or a further 2 years
  if she is under 50 years old .
 Benign conditions is most
frequent causes of PMB but
 endometrial cancer is the
   most serious potential
     underlying cause
75% of women with
 endometrial cancer
are postmenopausal.
 Risk factors for endometrial cancer

are conditions typically associated with chronic elevations
  of endogenous estrogen levels or increased estrogen
  action at the level of the endometrium. These include
 Obesity.
 history of chronic anovulation.
 diabetes mellitus.
 estrogen-secreting tumors.
 exogenous estrogen unopposed by progesterone .
 tamoxifen use.
 a family history of Lynch type II syndrome (hereditary
  nonpolyposis colorectal, ovarian, or endometrial cancer).
Investigate all bleeding during menopause
  unless the patient is on cyclic replacement
  therapy with normally anticipated
  withdrawal bleeding.

The duration or amount (staining vs gross)
 of bleeding does not make any difference.
            Tamoxifen use
Tamoxifen therapy is associated with a two-
  to threefold increased risk of endometrial
  cancer in postmenopausal women. TVUS
  of patients on this therapy typically shows
  an increased endometrial thickness.
Risk appears to increase with higher
  cumulative doses of tamoxifen and longer
  duration of treatment.
 Postmenopausal bleeding and
           HRT
• The occurrence of uterine bleeding or
  spotting after the initiation of HRT is not
  unusual. More than half of HRT users will
  have some spotting or bleeding at the
  beginning of therapy.
• Usually such bleeding is lighter than a
  menstrual period and lessens with time;
  after 6 months, it stops completely in most
  women.
 Postmenopausal bleeding and
           HRT
Sequential (or cyclical) combined regimens
 cause scheduled bleeding in most users.
 Continuous combined regimens are
 associated with a reduced relative risk of
 endometrial cancer but may cause
 unpredictable spotting or bleeding during
 initial use.
   Systemic conditions
Abnormalities of the hematologic system also
  must be considered as a possible cause of
  postmenopausal bleeding.
On rare occasions, AUB will be the first sign of
  leukemia or a blood dyscrasia.
 Overuse of anticoagulant medications such as
  aspirin, heparin, and warfarin-which are
  taken with greater frequency by patients in
  this age group-may contribute to
  postmenopausal bleeding.
• Once menopause occurs, estrogen and
  progesterone are no longer produced by the
  ovaries; nor are they produced in any
  appreciable amounts by the liver and fat.
  The endometrium regresses to some
  degree, and no further bleeding should
  occur. When bleeding does resume,
  therefore, endometrium must be evaluated.
Endometrial evaluation is called for when :
1. any menopausal woman not taking HRT
   develops uterine bleeding after more than 1
   year of amenorrhea.
2. any postmenopausal woman on HRT for 6
   months or more with persistent uterine
   bleeding.
3. and any previously amenorrheic woman on
   HRT who begins bleeding without apparent
   cause.
As TVUS is a non invasive test with 91 % sensitivity
    and 96 % specificity . it should be done for all
    women with postmenopausal bleeding.
if the endometrial thickness is >5mm. and if the
    patient pre test probability is low ,office endometrial
    biopsy and SIS should be done to determine
    whether the endometrium is symmetrically
    thickened.
BUT if the patient pre test probability is high , a
    fractional curettage biopsy or a hysteroscopic
    guided biopsy is recommended.
                                     TVUS
            endometrial                                       endometrial
       thickness is > 5mm                                thickness is < 5mm



  If low risk              If high risk                                 follow




office endometrial             D/C biopsy OR                       But symptoms
 biopsy and SIS                 hysteroscopy                           persist



 In women with continued bleeding after a negative initial evaluation, further testing
 with hysteroscopically directed biopsy is essential,
Vaginal ultrasonography.
Hydrosonography.
Endometrial biopsy.
        Office biopsy.
        D/C biopsy.
        Hysteroscopic guided biopsy.
Sensitivity and specificity are
 often used to summarise the
 performance of a diagnostic
 test. Sensitivity is the probability
 of testing positive if the disease
 is truly present. Specificity is the
 probability of testing negative if
 the disease is truly absent.
Transvaginal ultrasound has a good correlation
  with pathologic endometrial findings. Using an
  endometrial thickness from myometrium to
  myometrium of 5 mm (considered the upper limit
  of normal) sensitivity is 91 percent and
  specificity is 96 percent.

Although the test is very specific , it isn't sensitive.
  Many women without endometrial cancer will
  have an endometrial thickness of 5 mm or more
Identification and measurement
  of the endometrial echo and
  descriptions of the echogenicity
  and heterogeneity of the
  endometrium are key to defining
  endometrial health
    A cut-off threshold of 3 mm or 5mm ?

A ‘negative’ TVUS result for a local cut-off
  point of 3 mm is therefore less likely to
  miss cancer (i.e. have a greater sensitivity)
  than cut-offs of 5 mm.
But unfortunately a lower cut-off points also
  result in a greater proportion of ‘false
  positives’ requiring further investigation.
   A cut-off threshold of 3 mm or 5mm ?


Adopting more than one cut
 off value may allow the
 interpretation of the test to
 be tailored to the patient’s
 pre-test probability (i.e. the
 patient risk group).
        the patient risk group

•Low pre-test probability
•On HRT                     •High pre-test
•On tamoxifen therapy       Probability (high risk)




 Cut off threshold 5mm      Cut off threshold 3mm
If both pre-and post test
  probability are reassuring, no
  further action need be taken.
  Further investigations should
  be carried out if symptoms
  recur.
If both pre-and post test
  probabilities are not satisfactory
  with this level of reassurance,
  further investigation is justified.
  This should include an
  endometrial biopsy to obtain a
  histological assessment.
For women on sequential
 combined HRT presenting with
 unscheduled bleeding, or
 those who are tamoxifen users,
 TVUS using a cut-off point of 5
 mm or less should be used to
 exclude endometrial cancer.
One of the difficulties with using the
 endometrial stripe as a criterion for further
 diagnostic tests (eg, endometrial biopsy) is
 that several conditions may be present
 that give a false reading on the
 endometrial stripe. This is particularly true
 in a patient who might have an
 endometrial polyp or who has been taking
 tamoxifen.
The introduction of intrauterine fluid
 (saline-infusion sonography)
 during transvaginal ultrasound is
 one of the most significant
 advances in ultrasonography of
 the past decade.
Uterine fibroids and adenomyomas generally
 are apparent on ultrasound. Uterine polyps
 may appear as a thickened endometrial
 stripe, but these and submucous myomas
 can be clearly identified as filling defects
 when a sonohysterography is performed
At transvaginal US, when the endometrium
  cannot be accurately measured or when there
  is a nonspecific thickened central endometrial
  complex, sonohysterography can provide
  additional information and can be used to
  direct the patient to a visually guided
 hysteroscopic procedure rather than a
 potentially unsuccessful blind biopsy
 procedure.
At transvaginal ultrasonography , the finding of
  a thickened central endometrial complex,
  with or without cystic changes, is often
 nonspecific.
The Thickened endometrium may
be a polyp
                                                          CYST




                                                 POLYP


With polyps the endometrial-myometrial
interface is preserved                   well-defined, homogeneous,
                                         isoechoic to the endometrium
The Thickened endometrium may be a
polyp




                                         catheter
With polyps the endometrial-myometrial              POLYP
interface is preserved
The Thickened endometrium may
be a Submucosal leiomyomas




With myomas the endometrial-
myometrial interface is distorted   broad-based, hypoechoic,
The Thickened endometrium may
be an endometrial hyperplasia
               Endometrium thickness = A-B




                                               A
                                       B


               diffuse thickening of the echogenic
               endometrial stripe without focal
               abnormality
  Endometrial cancer
Endometrial cancer is typically a diffuse process,
but early cases can appear as a polypoid mass
         Dilatation and curettage


The role today of the formal D&C
 probably is very limited because
 the diagnosis usually can be
 made in the office.
                Hysteroscopic-directed
                       biopsy
Hysteroscopic visualization has several advantages:
immediate office evaluation,
visualization of the endometrium and endocervix,
the ability to detect minute focal endometrial
 pathology and to perform directed endometrial
 biopsies.

								
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