Curriculum · Gynecology / Women's Health / Infertility / Perinatal Care / Birth Spacing
Postmenopausal bleeding and endometrial carcinoma
What it is
Postmenopausal bleeding has an incidence of 4-11%. The differential is endometrial atrophy, polyp, hyperplasia and carcinoma, with submucosal fibroid, which is uncommon. Atrophy, vaginal or endometrial, is the most common, and endometrial cancer is the one that has to be excluded. Endometrial cancer presents as abnormal vaginal bleeding: intermenstrual bleeding, frequent cycles under 21 days or prolonged periods over 8 days before menopause, and postmenopausal bleeding after it. It can also give vaginal discharge and pelvic pain.
Causes and risk
Risk comes above all from high estrogen exposure: nulliparity, early menarche and late menopause. Obesity adds to it because adipose tissue turns androgen into estrogen. The rest are chronic anovulation as in PCOS, the iatrogenic ones of HRT and tamoxifen, Lynch syndrome, and a family hx of breast, ovarian, endometrial or colorectal Ca. A nulliparous woman with DM over 70 yr old carries an 85% risk of cancer. Polyp is higher with estrogen therapy, tamoxifen or obesity.
How it presents
Vaginal atrophy from low estrogen looks pale, dry, shiny and smooth, with loss of rugation; with inflammation there is patchy erythema, patechia, visible blood vessels and bleeding. On speculum examination a vaginal laceration can come from that atrophy, and bimanual examination finds a pelvic mass in advanced cancer, large and fixed.