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1.
2.
Postmenopausal bleeding
3.
4.
gsgseb@sun.ac.za
Estradiol
Progesterone
LH
14
28
Anovulation
LH
FSH
Estradiol
Progesterone
0
14
28
Gynaecological bleeding
Estrogen withdrawal
Estrogen breakthrough
Progesterone withdrawal
Progesterone breakthrough
Estrogen withdrawal
After oophorectomy
Midcycle
Estrogen withdrawal
Estrogen breakthrough
Estrogen breakthrough
Progesterone withdrawal
Progesterone breakthrough
=often anovulatory
Diagnosis
Pregnancy test
Gynaecological examination
Women 20-35
Normal weight
No abnormal findings
Treatment
Progesterone therapy
Treatment
Oral contraception
Low dose combination monophasic
Brevinor
Nordette
Femodene
Minulette
Melodene
Minesse
Mirelle
Marvelon
Mercilon
Treatment
Progesterone therapy
Diagnostic procedures
Pelvic ultrasound
Endometrial sampling
D&C
Clotting profile
Hysteroscopy
Treatment
Estrogen therapy
Treatment
Estrogen therapy
Treatment- emergency
Estrogen therapy
Antifibrinolytic drugs
Hormone therapy
Treatment- surgical
Endometrial ablation
Hysterectomy
2. Postmenopausal bleeding
Menopause: diagnosis retrospective
Postmenopausal bleeding: any vaginal
bleeding (even bloody discharge) after at
least 6 months amenorrhoea, at the age of
the menopause
Malignant until proven otherwise
Menstruation after 55/ abnormal
menstruation ominous
CAUSES
Management
History
Clinical examination
Cytology smear
Ultrasound
Histology
Postmenopausal
bleeding
Cytology
VCE smear
Ultrasound
Ultrasound: atrophy
Thickness: 4mm or
less (5mm)
Regular
No fluid collections
Ultrasound: histology
Thickness: >4mm
Irregular
Fluid collections
(cone biopsy!)
Histology
Management
Atrophy
local estrogen cream for one
month
hormone replacement therapy
Management
Malignancy
refer to gynaecologist/ oncologist
Endometrial hyperplasia
Simple hyperplasia
without atypia
with atypia
1%
8%
Complex hyperplasia
without atypia
with atypia
3%
29%
Management
Management
Vaginitis (atrophic)
Treat cause
Refer to endocrinologist
Remove
Vaginitis (atrophic)
Refer to oncologist
-Conservative
4. Abnormal bleeding on
contraceptives
23 August 2002
4. Bleeding on contraceptives
Slight bleeding
exclude pathology (ectopy, polyps)
reassure
bleeding only needs treatment if it
persists or is excessive
4. Bleeding on contraceptives
Bleeding shortly after
commencement of depo MPA
repeat another 150-300 mg
only instance where this approach will
work
based on inadequate endometrial
suppression
4. Bleeding on contraceptives
Bleeding after long-term use of
depo MPA
Usually due to atrophic endometrium
Exclude pathology
Add estrogen 20 microgram po, daily
for three weeks/month x2-3 months
(+ continue Depo)
4. Bleeding on contraceptives
Breakthrough bleeding on oral contraceptives
Exclude pathology
In first half of cycle- usually due to insufficient
estrogen stimulation
Minor bleeding- continue pill and wait
Change to pill with higher estrogen content if
bleeding persists (eg Biphasil)
Regard severe breakthrough bleeding as a
menstruation and start a new packet
4. Bleeding on contraceptives
Breakthrough bleeding on oral
contraceptives
In second half of cycle- usually due to
insufficient progestogen stimulation
Change to pill with higher
progestogen content (eg Nordiol,
Ovral, Norinyl)
Thank you
gsgeb@sun.ac.za
www.sun.ac.za/obs