Materiały źródłowe

• #1 Postmenopausal Bleeding (PMB) | Doctor

  https://patient.info/doctor/postmenopausal-bleeding

  Postmenopausal bleeding (PMB) is defined for practical purposes as vaginal bleeding occurring after twelve months of amenorrhoea, in a woman of the age where the menopause can be expected. […] Although PMB usually has a benign cause, the priority is to exclude malignancy. […] PMB is a common problem representing 5% of all gynaecology outpatient attendances. These are most commonly to eliminate endometrial cancer as the cause of the bleed. […] Vaginal atrophy. The most common cause of PMB. […] History and examination may possibly indicate cause, but it is generally accepted that PMB should be treated as malignant, until proved otherwise. […] This requires referral to a gynaecologist with an appointment within two weeks. […] TVUS is an appropriate first-line procedure to identify which women with PMB are at higher risk of endometrial cancer.

• #2 Postmenopausal Bleeding – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/sites/books/NBK562188/

  Menopause is characterized by the complete absence of menstrual cycles, which occurs when a female has no ovarian follicles left in reserve and is clinically diagnosed when a woman has had amenorrhea for 1 year. […] Bleeding after menopause has been established, termed postmenopausal bleeding, is considered abnormal and is the reason for approximately two-thirds of all gynecologic office visits in postmenopausal women. […] The differential diagnoses associated with postmenopausal bleeding (PMB) include several conditions. Though the most common cause of PMB is atrophy of the lower reproductive tract, 90% of postmenopausal women diagnosed with endometrial cancer presented with vaginal bleeding. […] The most common etiology for postmenopausal bleeding is an atrophic endometrium. The hypoestrogenic environment following menopause leads to genitourinary atrophy. The collapsed and atrophic endometrial lining within the uterus contains scant or no fluid to prevent friction inside the cavity, causing epithelial microerosions and subsequent chronic inflammation. Chronic endometritis secondary to atrophy can present with vaginal spotting or light bleeding.

• #3 Postmenopausal Bleeding – Kamm McKenzie OBGYN

  https://www.kmobgyn.com/postmenopausal-bleeding/

  Bleeding after menopause is never normal and should always be reported to your provider. […] In 95% of cases, the cause of bleeding is non-cancerous; however, postmenopausal bleeding is sometimes the first symptom of uterine cancer. […] Some causes of postmenopausal bleeding include the following: Endometrial or vaginal atrophy: This is when the lining of the uterus or vagina become so thin from lack of estrogen that it gets irritated and bleeds. […] Endometrial hyperplasia: This is an abnormal thickening of the uterine lining usually due to an excess of estrogen. This lining can sometimes become abnormal and eventually lead to cancer. […] Anyone with postmenopausal bleeding should have an evaluation. […] Treatment for your abnormal bleeding is dependent on the cause and this can be discussed with your provider.

• #4 Is postmenopausal bleeding a concern? – Mayo Clinic Health System

  https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/postmenopausal-bleeding-should-you-be-concerned

  Menopause is a normal, physiological event that can occur naturally or be induced through medical interventions, such as surgery, pelvic radiation therapy, chemotherapy or systemic illness. […] During menopause, women may experience a return of vaginal bleeding that may be light spotting or a heavy flow. In these situations, women should seek guidance from their care team. […] Bleeding after menopause is not normal. Although bleeding may be caused by your activity level, or by an infection or thinning of the vaginal or vulvar skin, it also could be a symptom of something more serious. Postmenopausal bleeding could be caused by uterine polyps or fibroids, thyroid abnormalities, bleeding disorders or thinning of the lining of the uterus, called atrophy. […] More serious causes of postmenopausal bleeding include cancer and hyperplasia, which is the formation of abnormal cells within the lining of the uterus.

• #5 Postmenopausal Bleeding – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK562188/

  The most common etiology for postmenopausal bleeding is an atrophic endometrium. The hypoestrogenic environment following menopause leads to genitourinary atrophy. The collapsed and atrophic endometrial lining within the uterus contains scant or no fluid to prevent friction inside the cavity, causing epithelial microerosions and subsequent chronic inflammation. Chronic endometritis secondary to atrophy can present with vaginal spotting or light bleeding. Pelvic ultrasounds performed in these patients typically reveal a thin endometrial stripe with an otherwise normal appearance, a small uterus, and small ovaries. […] Conversely, unopposed estrogen exposure often develops premalignant or malignant endometrial conditions. Systemic estrogen-only therapy, obesity, and estrogen-secreting tumors can lead to abnormal endometrial changes. Some women have genetic predispositions to endometrial cancer, eg, Lynch syndrome and Cowden disease. More recent studies demonstrate that BRCA gene mutation carriers may have a slightly increased risk of endometrial cancer, especially those with a BRCA1 mutation.

• #6 WHO EMRO | Histological findings in women with postmenopausal bleeding: Jordanian figures | Volume 17, issue 7 | EMHJ volume 17, 2011

  https://www.emro.who.int/emhj-volume-17/volume-17-issue-7/article5.html

  Postmenopausal bleeding represents one of the most common reasons for referral to gynaecological services. […] A woman not taking hormone replacement therapy (HRT) who bleeds after the menopause has a 10% risk of having genital cancer and a further 10% risk of significant pathology. […] Endometrial atrophy is the most common endometrial finding in women with postmenopausal bleeding, accounting for 60%80% of such bleeding. […] Oestrogen is an established risk factor for endometrial hyperplasia and cancer. […] Clinically significant hyperplasia usually evolves within a background of proliferative endometrium as a result of protracted oestrogen stimulation in the absence of progesterone influence. […] Not only is endometrial hyperplasia important because of the possibility of abnormal uterine bleeding but it may also precede or occur simultaneously with endometrial cancer.

• #7 „Postmenopausal Bleeding” From StatPearls – Tom Wade MD

  http://www.tomwademd.net/postmenopausal-bleeding-from-statpearls/

  Lack of estrogen causes atrophy of the vagina and endometrium. Inside the uterus, the collapsed and atrophic surfaces of the endometrium contain scant or no fluid to prevent friction inside the cavity. This leads to the development of micro-erosions of the epithelial surface, with subsequent chronic inflammation. This chronic endometritis is prone to spotting or light bleeding. […] On the other hand, premalignant or malignant conditions of the endometrium often arise after unopposed estrogen. Systemic estrogen-only therapy, chronic anovulation (such as in polycystic ovarian syndrome), obesity, and estrogen-secreting tumors can lead to abnormal endometrial changes. Anovulation also leads to infrequent, insufficient shedding of the endometrium. Some women have genetic predispositions to endometrial cancer, including Lynch syndrome and Cowden disease.

• #8 Postmenopausal Bleeding – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/sites/books/NBK562188/

  Conversely, unopposed estrogen exposure often develops premalignant or malignant endometrial conditions. Systemic estrogen-only therapy, obesity, and estrogen-secreting tumors can lead to abnormal endometrial changes. Some women have genetic predispositions to endometrial cancer, eg, Lynch syndrome and Cowden disease. […] The hypoestrogenic environment has several effects on the postmenopausal endometrium that are apparent on microscopic examination. Normal premenopausal proliferative endometrium contains regularly spaced, ordered glands lined by simple epithelial cells within the stroma with an approximate 1 to 1 gland-to-stroma ratio. […] Pathologic endometrial findings have varying histologic findings depending on the underlying etiology. For instance, the histopathology of endometrial polyps frequently shows cellular immaturity with cystic hyperplasia, while smooth muscle fibers are a characteristic finding of uterine fibroids. Both conditions have a higher risk of malignant transformation in postmenopausal women.

• #9 Postmenopausal Bleeding | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/27521

  Conversely, unopposed estrogen exposure often develops premalignant or malignant endometrial conditions. Systemic estrogen-only therapy, obesity, and estrogen-secreting tumors can lead to abnormal endometrial changes. Some women have genetic predispositions to endometrial cancer, eg, Lynch syndrome and Cowden disease. More recent studies demonstrate that BRCA gene mutation carriers may have a slightly increased risk of endometrial cancer, especially those with a BRCA1 mutation.

• #10 Bleeding – perimenopausal, postmenopausal and breakthrough bleeding on MHT/HRT – Australasian Menopause Society

  https://www.menopause.org.au/hp/information-sheets/postmenopausal-bleeding-including-breakthrough-on-mht-hrt

  Postmenopausal bleeding (PMB) refers to any vaginal bleeding that occurs in a menopausal woman ie. 12 months after their final menstrual period. This does not include the regular withdrawal bleed that occurs on MHT. […] Any postmenopausal bleeding requires investigation to exclude a sinister cause. The likelihood of endometrial carcinoma for a woman presenting with PMB is 10%. However, around 95% of women with endometrial malignancy will present with PMB. Risk factors for endometrial cancer include age, obesity, use of unopposed oestrogen, polycystic ovary syndrome, Type 2 diabetes mellitus, atypical glandular cells on screening cervical cytology and family history of gynaecologic malignancy. Nulliparity is also a risk factor. Patients taking non-conventional MHT, such as troches and transdermal progestogen are at risk of endometrial hyperplasia and cancer.

• #11 Abnormal Uterine Bleeding | AAFP

  https://www.aafp.org/pubs/afp/issues/2004/0415/p1915.html

  Abnormal uterine bleeding includes vaginal bleeding 12 months or more after the cessation of menses, or unpredictable bleeding in postmenopausal women who have been receiving hormone therapy for 12 months or more. […] Anovulatory dysfunctional uterine bleeding is a disturbance of the hypothalamic-pituitary-ovarian axis that results in irregular, prolonged, and sometimes heavy menstrual bleeding. It may occur immediately after menarche but before maturation of the hypothalamic-pituitary-ovarian axis, or it may occur during perimenopause, when declining estrogen levels fail to regularly stimulate the LH surge and resulting ovulation. […] Unopposed estrogen stimulation may lead to endometrial proliferation and hyperplasia. Without sufficient progesterone to stabilize and differentiate the endometrium, this mucous membrane becomes fragile and sloughs irregularly. Estrogen also affects uterine vascular tone, angiogenesis, prostaglandin formation, and endometrial nitric oxide production.

• #12 Bleeding – perimenopausal, postmenopausal and breakthrough bleeding on MHT/HRT – Australasian Menopause Society

  https://menopause.org.au/hp/information-sheets/postmenopausal-bleeding-including-breakthrough-on-mht-hrt

  Postmenopausal bleeding (PMB) refers to any vaginal bleeding that occurs in a menopausal woman ie. 12 months after their final menstrual period. This does not include the regular withdrawal bleed that occurs on MHT. […] Any postmenopausal bleeding requires investigation to exclude a sinister cause. The likelihood of endometrial carcinoma for a woman presenting with PMB is 10%. However, around 95% of women with endometrial malignancy will present with PMB. […] Patients taking non-conventional MHT, such as troches and transdermal progestogen are at risk of endometrial hyperplasia and cancer. […] Bleeding should be investigated if it occurs after six months use of CCMHT or tibolone, or starts after amenorrhoea has been established on this regimen. Amenorrhoea in this setting depends upon the balance between the oestrogenic effect and progestogenic effect of the MHT components on the endometrium. Oestrogen stimulation of the endometrium causes proliferative histological features and progesterone secretory. Inadequate progestogenic effect can therefore result in endometrial proliferation and possibly hyperplasia and bleeding. It may, like unopposed oestrogen therapy, lead to endometrial malignancy. However, more commonly in women taking pharmaceutical preparations of CCMHT, excessive progestogenic effect may produce bleeding from an atrophic endometrium.

• #13 Endometrial Hyperplasia > Fact Sheets > Yale Medicine

  https://www.yalemedicine.org/conditions/endometrial-hyperplasia

  Endometrial hyperplasia is a precancerous condition in which there is an irregular thickening of the uterine lining. This may cause uncomfortable symptoms for women, including heavy menstrual periods, postmenopausal bleeding, and anemia due to the excess bleeding. […] The root cause of endometrial hyperplasia is an imbalance between estrogen and progesterone; the condition may mean that the lining is not fully shed each month. When there is an unusual thickening of the uterine lining, it can result in what is known as endometrial hyperplasia. The condition is associated with heavy menstrual periods, short menstrual cycles (oligomenorrhea), and postmenopausal bleeding. […] For women with endometrial hyperplasia who have abnormal, non-cancerous cells, progestin therapy may be recommended. This synthetic hormone helps to balance out the effects of estrogen in the system, which should eliminate or minimize symptoms of endometrial hyperplasia.

• #14 WHO EMRO | Histological findings in women with postmenopausal bleeding: Jordanian figures | Volume 17, issue 7 | EMHJ volume 17, 2011

  https://www.emro.who.int/emhj-volume-17/volume-17-issue-7/article5.html

  The incidence of endometrial carcinoma in studies published between 1985 and 2004 varied between 3.7% and 17.9%. […] Although the rate of postmenopausal bleeding declined with increasing age, the peak incidence of endometrial carcinoma occurred in the age group 7074 years. […] Adenomatous hyperplasia, with or without atypia, is considered to be a precursor of carcinoma and was found in about 11% of women in the present study. […] The relatively low incidence of hyperplasia as the cause of bleeding could be due both to the strict selection of postmenopausal women and to the fact that none had been treated with oestrogen replacement therapy. […] In our study 3% of the postmenopausal women had an endometrium characterized as secretory. […] These observations support the use of transvaginal scan ultrasound in the evaluation of postmenopausal bleeding, especially since endometrial carcinoma has been found to be extremely rare in women with an endometrial thickness less than 5 mm. […] It is important to note that about 50% of the women with postmenopausal bleeding had an atrophic endometrium, which is similar to other parts of the world including this region.

• #15 Menorrhagia: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/255540-overview

  Knowledge of normal menstrual function is imperative in understanding the etiologies of menorrhagia. […] The mechanism by which endometrial polyps or fibroids cause menorrhagia is not well understood. […] This blood supply is greater than the endometrial supply and may have impeded venous return, causing pooling in the areas of the fibroid. […] Heavy pooling is thought to weaken the endometrium in that area, and break-through bleeding ensues. […] Anatomic defects or growths (most typically polyps or fibroids but also malignancy) within the uterus can alter either of the aforementioned pathways (endocrinologic/hemostatic), causing significant uterine bleeding. […] Organic diseases also contribute to menorrhagia in the female patient. […] Due to the overwhelming factors that can contribute to the dysfunction of either the endocrine or hematologic pathways, in-depth knowledge of an existing organic disease is just as imperative as understanding the menstrual cycle itself.

• #16 Vaginal Bleeding – Gynecology and Obstetrics – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/gynecology-and-obstetrics/symptoms-of-gynecologic-disorders/vaginal-bleeding

  Most abnormal vaginal bleeding involves […] Hormonal abnormalities in the hypothalamic-pituitary-ovarian axis […] Ovulatory dysfunction is due to endocrine abnormalities. As a result, ovulation does not occur or occurs infrequently or irregularly. During an anovulatory cycle, the corpus luteum does not form, and thus the normal cyclical secretion of progesterone does not occur. Without progesterone, estrogen causes the endometrium to continue to proliferate, eventually outgrowing its blood supply. The endometrium then sloughs and bleeds incompletely, irregularly, and sometimes profusely or for a long time. […] Benign structural disorders (eg, uterine fibroids, adenomyosis) may cause abnormal bleeding because they interfere with the function of the myometrium (muscle layer of the uterus). Endometrial or cervical polyps have dense, fragile blood vessels and bleed easily. […] In postmenopausal women with vaginal bleeding, further evaluation should be done for gynecologic cancer.

• #17 Postmenopausal Bleeding – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/sites/books/NBK562188/

  One of the most concerning etiologies of postmenopausal bleeding is endometrial cancer, which is typically subclassified into type I or II based on histologic morphology, grade, and hormone receptors. […] The primary complication of PMB is secondary anemia, which occurs in approximately 10% of postmenopausal women. Other complications that may occur are typically associated with the underlying etiology.

• #18 Bleeding After Menopause: Causes, Concerns, and SolutionsAccessibility ToolsIncrease TextDecrease TextGrayscaleHigh ContrastNegative ContrastLight BackgroundLinks UnderlineReadable FontReset

  https://roswellobgyn.org/blog/bleeding-after-menopause-causes-concerns-and-solutions/

  This overgrowth causes irregular and heavy bleeding, even after menopause, and is not cancerous. […] Endometrial cancer is a type of cancer that starts in the lining of the uterus and is the most common type of uterine cancer that can cause significant postmenopausal bleeding. […] Bleeding occurs because cancerous cells invade and disrupt the normal structure and function of the endometrial lining. […] Cervical cancer originates in the cells of the cervix, the lower part of the uterus that connects to the vagina. […] Postmenopausal bleeding can occur if cancerous lesions develop on the cervix, causing irritation and bleeding.

• #19 The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding | ACOG

  https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/the-role-of-transvaginal-ultrasonography-in-evaluating-the-endometrium-of-women-with-postmenopausal-bleeding

  Cancer of the endometrium is the most common type of gynecologic cancer in the United States. Vaginal bleeding is the presenting sign in more than 90% of postmenopausal women with endometrial carcinoma. […] The clinical approach to postmenopausal bleeding requires prompt and efficient evaluation to exclude or diagnose endometrial carcinoma and endometrial intraepithelial neoplasia. Transvaginal ultrasonography usually is sufficient for an initial evaluation of postmenopausal bleeding if the ultrasound images reveal a thin endometrial echo (less than or equal to 4 mm), given that an endometrial thickness of 4 mm or less has a greater than 99% negative predictive value for endometrial cancer. […] Transvaginal ultrasonography is not an appropriate screening tool for endometrial cancer in postmenopausal women without bleeding.

• #20 Postmenopausal Bleeding > Fact Sheets > Yale Medicine

  https://www.yalemedicine.org/conditions/postmenopausal-bleeding

  If a woman is diagnosed with endometrial cancer, surgical removal of the uterus (hysterectomy), often along with the ovaries and fallopian tubes, may be needed. Local lymph nodes may also be biopsied to see if the cancer has spread. A woman may receive chemotherapy or radiation after surgery, depending on the circumstances of her diagnosis. […] Women who experience postmenopausal bleeding usually have positive outcomes. Medication and other treatment options should help to stop bleeding among women whose symptoms are due to non-cancerous causes. […] If a woman experiences postmenopausal bleeding because of endometrial cancer, early detection and treatment will help to improve the outcome.

• #21 Bleeding – perimenopausal, postmenopausal and breakthrough bleeding on MHT/HRT – Australasian Menopause Society

  https://menopause.org.au/hp/information-sheets/postmenopausal-bleeding-including-breakthrough-on-mht-hrt

  Tamoxifen therapy is associated with stimulation of the endometrium and an increased risk of endometrial cancer. Tamoxifen therapy invariably produces a thickened appearance to the endometrium which is not always indicative of neoplasia. […] Blind tissue sampling such as Pipelle or DC may be sufficient for pathology that affects the entire endometrial surface, but it is inadequate for detecting localised lesions such as endometrial polyps, which may be malignant. Hysteroscopy is superior to endometrial biopsy and ultrasonography for the identification of these structural lesions and is recommended.

• #22 Bleeding after menopause: It’s not normal | Cancer | UT Southwestern Medical Center

  https://utswmed.org/medblog/postmenopausal-bleeding/

  I urge women to treat postmenopausal bleeding as cancer until proven to be something else. […] Sometimes the lining of the uterus becomes thick, usually because of too much estrogen and too little progesterone. This is considered a precursor to endometrial cancer. […] Treatment for postmenopausal bleeding depends on its cause. […] When postmenopausal bleeding is diagnosed as endometrial cancer, most cases can be cured with a hysterectomy. However, because endometrial cancer can spread into the lymph nodes, many patients also should have a lymph node dissection at the time of hysterectomy. […] Seeing a gynecologic oncologist immediately after diagnosis can avoid these complications, simplifying care and improving the chance of survival.

• #22 Bleeding after menopause: It’s not normal | Cancer | UT Southwestern Medical Center

  https://utswmed.org/medblog/postmenopausal-bleeding/

  Too often I see women with advanced endometrial cancer (uterine cancer) who tell me they experienced postmenopausal bleeding for years but didnt think anything of it. This shows we need to do a better job educating our patients about what to expect after menopause. […] Women need to know postmenopausal bleeding is never normal, and it may be an early symptom of endometrial cancer. Any bleeding, even spotting, should trigger a visit to your doctor as soon as possible. […] A variety of conditions can cause postmenopausal bleeding, including hormone therapy, infection, or the use of medications such as blood thinners. […] Postmenopausal bleeding is a common symptom of endometrial cancer, but it also can be caused by cervical and vulvar cancer. […] Early diagnosis offers the best chance to beat endometrial cancer.

• #23 Postmenopausal Bleeding (PMB) | Doctor

  https://patient.info/doctor/postmenopausal-bleeding

  The thicker the endometrium, the higher the likelihood of important pathology, ie endometrial cancer being present. […] Most women with PMB will not have significant pathology but the dictum remains that postmenopausal bleeding is cancer until proved otherwise. […] Women with breast cancer who take tamoxifen on a long-term basis are at increased risk of endometrial cancer.

• #24 The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding | ACOG

  https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/the-role-of-transvaginal-ultrasonography-in-evaluating-the-endometrium-of-women-with-postmenopausal-bleeding

  Postmenopausal vaginal bleeding usually is caused by atrophic changes of the vagina or endometrium. Depending on age and risk factors, 114% of women with postmenopausal bleeding will have endometrial cancer. […] Because rare cases of endometrial carcinoma (particularly type II) can present with an endometrial thickness of less than 3 mm, persistent or recurrent uterine bleeding should prompt a histologic evaluation of the endometrium regardless of endometrial thickness. […] Failure to adequately identify a thin, distinct endometrial echo in a postmenopausal woman with bleeding should trigger sonohysterography, office hysteroscopy, or endometrial sampling. […] An endometrial measurement greater than 4 mm that is incidentally discovered in a postmenopausal patient without bleeding need not routinely trigger evaluation, although an individualized assessment based on patient characteristics and risk factors is appropriate.

• #25 Abnormal Uterine Bleeding | AAFP

  https://www.aafp.org/pubs/afp/issues/1999/1001/p1371.html

  Hysteroscopy with biopsy allows visualization of the endometrial cavity and is regarded as the gold standard for endometrial assessment. […] Endometrial biopsy and transvaginal ultrasonography have comparable costs. […] Hysteroscopy with biopsy provides the most comprehensive evaluation of the endometrium and is recommended for use in any woman with equivocal findings on biopsy or ultrasonography.

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