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DESCRIPTION
Postmenopausal uterine bleeding (PMB) is defined as unexpected, vaginal bleeding that begins 6 to 12 or more months after menopause.
FREQUENT SIGNS & SYMPTOMS
Vaginal bleeding, which may be a light-brown discharge or heavy, red bleeding (with or without clots). Mucus may accompany the bleeding. Bleeding episodes vary in length. The type or quality of the bleeding is not as relevant as the fact that it has taken place. Following menopause, women who are being treated with hormonal replacement therapy will likely encounter some bleeding and should consult with her health care provider about the types of bleeding to be concerned about.
Pelvic pain (sometimes).
CAUSES
There are many causes of postmenopausal bleeding.
The most common is hormone replacement therapy. Women who are taking hormone replacement therapy very often may develop PMB because the uterine lining is very sensitive to estrogen, which promotes growth of the endometrium, just as it does in the normal reproductive cycle that was operative prior to menopause. Lack of estrogen, on the other hand, may cause atrophy of the lining, and in this condition, the blood vessels of the uterine lining become so fragile because of estrogen lack that they spontaneously break and then bleed.
Overgrowth of the uterine lining is called "hyperplasia", may be the cause of abnormal post-menopausal bleeding, Some specific types are associated with a malignant potential. About 20 percent of true post-menopausal bleeders may have cancer of the endometrium (the uterine lining).
Cancer of the reproductive system ( uterine, cervical, ovarian, vulvar or vaginal cancer , etc.).
Irritation or infection of the membranes lining the vulva.
Vaginal or endometrial atrophy (shrinking or wasting away of tissue).
Injury or trauma to the vagina, associated with reduced estrogen levels.
Polyps or benign tumors of the cervix.
Polyps on the inner uterine lining: Myoma - Polyps and fibroids are common benign growths that develop in the uterine cavity. The former is most often associated with irregular light spotting, staining or actual light bleeding. The latter may also present this way, but in fact may be associated with much heavier bleeding.
Hormone therapy that stimulates the endometrium (uterine lining), causing sloughing similar to normal menstruation. Estrogens (female hormones) used irregularly are a common cause of this.
Disorders of the blood cells, lymphatic system or bone marrow.
High blood pressure (hypertension).
Congestive heart failure.
Liver disorders.
Anticoagulant or aspirin-containing drugs.
RISK INCREASES WITH
Recent vaginal infection.
Adult women over 60, due to fragile blood vessels and thin vaginal or uterine lining.
PREVENTIVE MEASURES
No specific preventive measures.
EXPECTED OUTCOME
Depends on the underlying cause and treatment chosen.
POSSIBLE COMPLICATIONS
Anemia.
If cancer is the cause, it may spread to other body parts.
TREATMENT
GENERAL MEASURES
DIAGNOSIS
Unexplained postmenopausal bleeding requires further testing. Diagnostic tests may include:LABORATORY BLOOD STUDIES - HRT & ESTROGEN LEVELS. One of the major concerns for women using estrogen for menopause management is the return of menstruation. For most women, menstruation after menopause, if they are taking hormone replacement therapy, is perfectly normal. Furthermore, it is a good sign and it simplifies menopause management for the clinician. Estrogen circulating in the blood is beneficial because of the effects on the skeleton, skin, and genital organs. To accomplish these effects, one needs to get a therapeutic level of the hormones which simulate the natural levels women experienced before menopause. Most practitioners agree that the minimum level of serum estrogen to achieve any tissue effects is approximately 60 pg/ml (picograms/ milliliter). At approximately 100 pg/ml, there is enough tissue effect on the lining of the uterus to simulate menstruation. Serum estrogen levels in normally menstruating women range from 100 to 300 pg/ml. From a positive perspective, bleeding during menstruation means that you are getting enough estrogen into your body to achieve a tissue effect. Monthly menstruation tells you that the medication is actually working.
There are several ways to take estrogen if your uterus has not been removed. If you are taking it with cyclic progesterone such as Provera (medroxyprogesterone acetate), than a short period 2-3 days after completing the progestin is totally normal. If you are taking estrogen and progesterone daily (not cyclically) and you occasionally have a little spotting, there is no cause for alarm. However, if you have irregular bleeding throughout the month, that is abnormal and you need to consult with your health care provider to make sure that there is no serious problem. The most typical problem is either a polyp or small fibroid within the uterine cavity. This can be diagnosed easily by transvaginal ultrasound. Only rarely is either malignant. The use of estrogen and progesterone combination therapy in any form reduces the risk of uterine cancer in women. Uterine cancer is a relatively uncommon cancer. In studies, the incidence of uterine cancer was cut by approximately 60% by taking combined hormone replacement therapy compared to non-users.
The traditional view has been that post-menopausal bleeding was bad and equaled uterine cancer until proven otherwise. Considering that the risk of having uterine cancer for post menopausal women taking combined hormone replacement therapy is less than 1/1000 and that many of these women will be having post menopausal bleeding - particularly if they have an adequate dose of hormone replacement therapy means that newer models for the management of post menopausal bleeding have to be developed.
MEDICAL HISTORY: A medical history is important in diagnosis of the underlying problem. The health care provider will need to know if the woman is using hormone replacement therapy (HRT) or if she has a history of known uterine fibroids, for example.
PELVIC EXAM & PAP SMEAR: A thorough pelvic examination of the vulva, vagina and cervix (including a PAP smear) should exclude causes in the lower genital tract.
UTERINE BIOPSY: A uterine biopsy requires the passing of a small tube-like device through the cervix and into the uterine cavity, suction is applied and small fragments of tissue are removed for microscopic examination.
ULTRASOUND: An ultrasound of the pelvic area. This study can delineate the thickness of the uterine lining, and perhaps the presence of a polyp or fibroid. Thickened endometrial lining can be seen spontaneously without significant underlying pathology, as a result of hormone therapy, in cases of hyperplasias or cancer, or because of other benign growths. A number of studies have been done which show that a thin uterine lining (less than 5 mm) is never associated with uterine cancer. One must remember that ultrasound examinations are the sophisticated interpretations of "shadows" and do not make an absolute diagnosis, as is the case with microscopic analysis. Thus, an abnormal ultrasound examination requires further investigation.
Another variation of vaginal ultrasound is hysterosonography where a small amount of fluid is placed in the uterine cavity at the same time the ultrasound is done. This outlines the contents of the uterine cavity. When there is a thickening of the cavity (more than 5 mm), hysterosonography is done. If the thickening is generalized, an endometrial biopsy is done in the office. If the thickening is localized, than a simple outpatient surgical procedure called a hysteroscopy ( where the health care provider looks inside of the uterus) and a D&C (a scraping out of the thickened area) is done.
TREATMENT
Specific therapy, usually medications or surgery, is dependent on the cause.
Hormone related post-menopausal bleeding is usually controlled by manipulation and alteration of hormone therapy. Certain hyperplasias may require extra progesterone-like supplementation in order to reverse this process. Polyps or fibroids protruding into the uterine cavity can removed with the hysteroscope, and the lining may then be sealed with electrical energy (endometrial ablation) to minimize any further PMB.DILATION & CURETTAGE (D&C): dilation and curettage (D&C) which is the dilation of the cervix and scraping out of the uterus with a curette that may be both diagnostic and a treatment to relieve the bleeding.
A "D&C" may be considered an old, essentially obsolete, procedure whereby a sharp spoon-like instrument is passed blindly through the cervix, and a scraping of the lining is performed in order to obtain tissue for microscopic analysis. More often than not, because it is truly a blind procedure, polyps and fibroids will be missed, as well perhaps as an early cancer. Hysteroscopy is far more precise and accurate. Some health care providers believe a "D&C" should be used only to evacuate the products of conception from the uterine cavity at the time of a miscarriage and A "D&C" is marginally useful for establishing an accurate diagnosis in the case of post-menopausal bleeding and is almost worthless or treatment.
HYSTEROSCOPY: This may include a hysteroscopic (telescopic instrument with fiberoptic light) examination. Hysteroscopy is a special test that entails the passing of a tiny telescope through the cervix allowing the actual visualization of the uterine cavity. Fibroids or polyps can be seen and removed, and suspicious area of tissue biopsied under direct vision.
HYSTEROSCOPIC & RESECTOSCOPIC ENDOMETRIAL ABLATION
Over the past decade, a technique has been developed that can reduce or stop your periods without a hysterectomy. This surgery can be done in women who have flooding either with or without fibroid tumors. This technique is called a hysteroscopic endometrial ablation or "roller ball surgery". Patients who have had this procedure have been followed for up to 10 years. During this period of time, they have experienced either complete, or almost complete, cessation of menses in over 90 percent of the cases. The "Roller ball" is done under general anesthesia or regional block (spinal or epidural). This is the outpatient procedure. Hospitalization is not necessary, except in rare instances.
Endometrial ablation has traditionally been done using a hysteroscope. Some practitioners have switched to using an instrument called a resectoscope. This resectoscope is a special type of telescope that allows the health care provider to see inside the uterus during the procedure. It has a built in wire loop that uses hight frequency electrical energy to cut or coagulate tissue. The resectoscope has the advantage of being able to remove polyps and some fibroids at the time of ablation. In results reported to the FDA where resectoscopic endometrial ablation was done by experts, the success rate was approximately 95 percent, with 40% of women having no bleeding whatsoever in 1 year. Practitioners report patients treated with the resectoscope as part of those trials, 58% of women had no bleeding at all after 1 year. It takes extensive experience and skill to be able to safely use the resectoscope, and obtain this degree of success.
Following the procedure, patients note a brownish to slightly bloody discharge, which occurs shortly after the procedure, and last up to 6 weeks. Patients are advised to refrain from any kind of exercise for at least 3-4 weeks because there have been reports of heavy bleeding following strenuous exercises (i.e., moving furniture, cutting wood, jogging). Half the patients will experience no side effects with the cautery technique, and are back to normal activity within 2-3 days: the other half will notice a cramp-like sensation, and are tired for several days. Over 90 percent of the patients are back to normal activity within 4-5 days after surgery. Most patients take 4-5 days off work following their surgery, although some individuals have returned to work within 24 hours.
This operation may cause sterility, but it is not guaranteed. However, if a woman chooses to be permanently sterile, a tubal ligation should be performed. Prior to using either cautery technique, it is important that the menstrual cycle be modified. This is achieved by taking tablets called danocine (Danazol) or medroxyprogesterone (Provera). Danocrine is a medication usually used for a condition called endometriosis. Generally, 2-4 pills a day are taken for 6 weeks. The side effects of Danocrine include weight gain, growth of hair, acne, and general malaise. The side effects of Provera include slight weight gain, depression, and PMS like symptoms. The third approach is an anti-hormone shot called Depo-Lupron. This medication causes a state of temporary menopause with hot flashes, vaginal dryness, and sleep disturbances. Because Depo-Lupron is quite costly ($500/month for 2 months), it is not used as often for preparation for this procedure. Following the cauterization of the uterine cavity, patients are often given an injection of a long-acting progesterone called medroxyprogesterone-depo (Depo-Provera). The shot will last approximately 3 months. During this time, a rare patient may experience mild depression. Bleeding is generally reduced when this medication is used post-operatively.
There is either reduction or cessation of the menstrual flow with this procedure. However, it takes 1 to 2 years to know exactly what the final results of the treatment will be. The complications of cauterization of the uterine lining include the risks of anesthesia and perforation of the uterus. A large volume of fluid is used during the procedure, and there is a rare chance of absorption of this fluid with mild alteration in blood products, i.e. electrolytes. The risk of perforation of the uterus is rare primarily because of the modifications that are employed in performing the technique and the skill of the practitioner. It takes extensive experience and skill to be able to safely use the Out of the first 100 women having this procedure, only 4 returned for a hysterectomy or more extensive gynecological surgery. 96 percent of the candidates were spared more extensive surgery.
This procedure has fewer surgical risks than a hysterectomy and provides an option to hysterectomy for stopping or reducing menstrual flow or for removing small fibroids or polyps while preserving a young woman's fertility. A new procedure called a Uterine Balloon Ablation was approved by the FDA in December, 1997.
UTERINE BALLOON ABLATION
This uses a balloon placed in the uterine cavity through the cervix. Hot water is circulated inside the balloon to destroy the endometrium. Some experts are concerned about the balloon's ability to reach the cornual areas (the "top corners") of the uterus. Although the balloon's "success" rate in FDA studies was reasonable, the it had a much lower rate of amenorrhea the other currently available device - only 13%. Some medical practitioners see no advantages and many disadvantages to it's use, so they may not recommend this device.
HYSTERECTOMY
Cancer obviously requires a much more aggressive treatment. A hysterectomy is the removal of the uterus (hysterectomy).
HOME TREATMENT TO EASE DISCOMFORT
While you are waiting for your diagnostic tests results to arrive, it may be helpful to take frequent lukewarm baths to relax muscles and relieve discomfort. Sit in a tub of water for 10 to 15 minutes as often as necessary. Use heat to relieve pain. Place a heating pad or hot water bottle on the abdomen or back when resting.
MEDICATION
If hormone medications are currently being taken, the dose may need to be adjusted. In other cases, hormones may be prescribed depending on the medical evaluation of the bleeding.
Medication to treat the underlying disorder, such as antihypertensives for high blood pressure.
ACTIVITY
Resume your normal activities as soon as symptoms improve.
Sexual relations may be resumed as soon as desired after diagnosis and treatment.
DIET
No special diet after treatment, but eat a well-balanced diet. Vitamin and mineral supplements are helpful to prevent anemia.
HELPFUL DIETARY PRODUCTS
Uterus Care, Balanceuticals - TCM Formula, 100% Natural, 60 Caps
Made of prepared rehmannia root, schizandra fruit, eucommia bark, dissacus, oyster shell, common yam, cuttlefish bone, garden burnet root, common peony root, typha pollen and red berried mistletoe. Chinese medicine uses this well-known formula to tonify the kidney and control the Yin, enhance excitability and tension of the uterus smooth muscles, promote regular contraction of the uterus, maintain normal blood flow and avoid excessive uterus bleeding. Direction for Use: As a dietary supplement, take 3~5 capsules 3 times daily. Not for use by pregnant woman. Store in a cool and dry place out of the reach of children.
Ashoka (Saraca indica), 450 mg, 120 Vcaps
Ashoka Powder (Saraca indica), 100% Organic, 8 oz. Bulk
This herb has been known to be used in uterine and uterine related indications. Helpful in managing conditions involving menhorragia (fibroids), bleeding hemorrhoids, hemorrhage, dysentry. The bark has a stimulating effect on the endometrial and ovarian tissues and is largely useful in menhorragia due to uterine fibroids, in leucorrhea and in internal bleeding, where ergot is indicated. It is well established for its effectiveness in dysmenorrhoea.Produces an estrogen-like effect that enhances the repair of the endometrial and stops bleeding. It is also useful in internal bleeding, hemorrhoids and also hemorrhagic dysentery.Oxytocie activity of the plant was seen in rat and human isolated uterine preparations. Estrogen-primed or gravid uterus was more sensitive to the action of the alcoholic extract. Pentolinium bitartrate completely blocked the oxytocic action. Seed extract is found effective against dermatophytic fungi. Its use in treatment of excessive uterine bleeding is extensive in India. The plant is used also in dysmenorrheal and for depression in women. Bleeding from piles is reduced with the plant. In the commonly used doses side effects are rare. Larger doses may cause constipation. Warnings: Do not take during pregnancy.
Ashwagandha (Withania somnifera), 450 mg, 120 Vcaps
Ashwagandha is well established for its effectiveness in dysmenorrhoea. Produces an estrogen-like effect that enhances the repair of the endometrial and stops bleeding. It is also useful in internal bleeding, hemorrhoids and also hemorrhagic dysentery. Oxytocic activity of the plant was seen in rat and human isolated uterine preparations. Estrogen-primed or gravid uterus was more sensitive to the action of the alcoholic extract. Pentolinium bitartrate completely blocked the oxytocic action. Seed extract is found effective against dermatophytic fungi. Its use in treatment of excessive uterine bleeding is extensive in India. The plant is used also in dysmenorrheal and for depression in women. Bleeding from piles is reduced with the plant. In the commonly used doses side effects are rare. Usage: 3 to 6 Vcaps Daily. Warnings: Do not take during pregnancy.
Female Regularity TCM Formula, Shenrong Dingkun, 60 Caps
Chinese medicine uses this time-honored formula to tonify the Qi and blood, activate female hormone, maintain healthy uterus smooth muscle tension, promotes gynecological regularity and postpartum recovery. It is also an analgesic. Direction for Use: As a dietary supplement, take 3~5 capsules 3 times daily. Not recommended for use by pregnant woman. Clinically, this product was used in menstrual disorders, sterility, and post partal deficiency. For Menstrual disorders: Mainly manifesting irregular menstrual cycle, profuse menstrual bleeding, light color and loose texture, lumbago, scanty blood, pink and clear blood like water, or with coagulated clots, leukorrhea, rubrorrhea, phthisis, hectic fever, massive hemorrhage, leaking blood, bloody fainting, bloody collapse, delayed or prior menstruation, menolipsis prior to climacteric period, functional uterine bleeding, uterine bleeding during puberty, climacteric period. This product is indicated for the above disorders.
Cinnamon Bark Tincture, 100% Organic, 2 fl. oz.
Cinnamon bark is warming to the body, an analgesic, carminative, antiseptic, and antibacterial. It is used to treat chronic diarrhea, cramps, heart and abdominal pains. Cinnamon Bark is also used to treat coughing, wheezing, and lower back pains. It is especially useful for stomach problems; colic, flatulence, indigestion, dysentery, and spasms. Cinnamon Bark can be used as a tincture every fifteen minutes to stop uterine bleeding. Suggested Dosage or Use: Use 6-12 drops in juice, water, under the tongue or as desired. May be taken 3 times daily.
Complete Tonic Uplifter, Shiquan Dabu, Balanceuticals, 60 Caps
Complete Tonic Uplifter (Shiquan Dabu) is made of extracts from Atractylodes, Poria, Licorice, Chinese angelica, Ligusticum, White peony, Prepared rehmania, Astragalus, Cinnamon bark, Panax ginseng, Chrysanthemum flower, Goji berry. Chinese medicine uses its overall blood and Qi tonifying, immune supporting, revitalizeing, invigorating and natural healing promoting properties for lack of energy, withered complexion, weakness in legs and joints, poor appetite, night emissions, uterine bleeding, depression and hot flashes. Directions: As a dietary supplement, take 3 capsules 3 times daily 30 minutes before meal.
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NOTIFY YOUR HEALTH CARE PROVIDER IF...
You or a family member has symptoms of postmenopausal bleeding. Women who are experiencing post-menopausal bleeding require investigation and the bleeding should not be written off as a normal "menopausal" experience.
Bleeding persists for 1 week, despite treatment.
Bleeding becomes excessive (saturates a pad more frequently than once each hour).
Signs of infection, such as general ill feeling, increasing pain, muscle aches, fever, headache and dizziness.
New, unexplained symptoms develop. Drugs used in treatment may produce side effects.
MoonDragon's Obgyn Information: Uterine Bleeding, Dysfunctional
