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Week 95 - Post Menopausal Bleeding

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Niranjan Gowda Y G
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9 views

Week 95 - Post Menopausal Bleeding

Uploaded by

Niranjan Gowda Y G
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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POSTMENOPAUSAL BLEEDING

Week 95
Prepared by: Holli Jakalow, MD
AuduBon-Bons
Reading Assignment:
Bite Sized 1. ACOG Practice Bulletin #734
Learning for Clinic The Role of Transvaginal Ultrasonography in
Evaluating the Endometrium of Women with
Postmenopausal Bleeding
2. Pearls of Exxcellence: Evaluation of
Postmenopausal Vaginal Bleeding
LEARNING OBJECTIVES
• To be able to define postmenopausal bleeding

• To understand the differential diagnosis for postmenopausal bleeding

• To know how to evaluate postmenopausal bleeding


CASE VIGNETTE
• Ms. Hydrangea, a 64 y.o. G3P2012 woman presents with new onset
bleeding.
FOCUSED HISTORY
What elements of the patient’s history are most relevant?
• PMH: Hypothyroidism
• PSH: Appendectomy, Right knee replacement
• POBH: NSVD x2, Surgical VTOP at 10 weeks gestation; all
uncomplicated
• PGYNH: Menopausal since age 51. Denies history of STIs or abnormal
paps. Up to date on pap with last pap at age 62. Has mutually
monogamous female partner. Denies history of fibroids or cysts.
Denies dyspareunia. Never took HRT.
• MEDS: Synthroid 150mcg daily
• ALL: NKDA
• FH: Mother had HTN and father had HLD. Denies family history of
cancers.
• SH: Retired. Lives with wife. Adult children live nearby and visit
often. Denies IPV. Drinks 3 glasses of wine each week. Denies
tobacco or drug use. Accepts blood products.
PERTINENT PHYSICAL EXAM FINDINGS
What elements of the patient’s physical exam are most relevant?
• VS WNL
• Gen: NAD
• Abd: Soft, ND, NT
• PE:
• Vulva: Moderately atrophic female genitalia. No lesions.
• Vagina: Mildly atrophic mucosa. No discharge.
• Cervix: Multiparous os. No lesions. No discharge. No CMT.
• Uterus: NT. Anteverted. Not enlarged.
• Adnexae: Not palpable.
• Groin: No inguinal lymphadenopathy.
• Rectum: No evidence of hemorrhoids or fissure, no masses on internal
exam
• Ext: WWP, no edema
POSTMENOPAUSAL BLEEDING

How do we define postmenopausal bleeding (PMB)?


• Any staining, spotting, or bleeding that occurs more than 12 months
after a person’s last menstrual period
DIFFERENTIAL DIAGNOSIS
What is the differential diagnosis of PMB?
• Vaginal or endometrial atrophy
• Most common!
• Polyps
• Fibroids
• Endometrial intraepithelial neoplasia (EIN)
• Endometrial cancer
• Vaginal bleeding is the presenting sign in >90% of postmenopausal patients with endometrial
cancer
• 1-14% of patient with PMB will be diagnosed with endometrial cancer
DIFFERENTIAL DIAGNOSIS

What are clinical risk factors for endometrial cancer?


• Age
• Obesity
• Use of unopposed estrogen
• PCOS
• T2DM
• Atypical glandular cells on screening cervical cytology
• Family history
EVALUATION OF POSTMENOPAUSAL BLEEDING

Trick Question: What assessment tool must be


considered when evaluating postmenopausal
bleeding?
• Transvaginal ultrasound OR Endometrial Biopsy
• Trick question because either can be used, but one must be used
• The initial evaluation does not require the use of both tests
EVALUATION OF POSTMENOPAUSAL BLEEDING

How do you decide to perform a TVUS or EMB as


first approach?
• EMB is always a reasonable first approach
• First-line test for women who have a higher risk of cancer or hyperplasia based on
clinical risk factors
• TVUS is reasonable to be used as a first approach if
• Initial episode of bleeding
• Patient’s probability of cancer or hyperplasia is low enough that no
additional evaluation would be warranted after a normal ultrasound
• Based on clinical risk factors
ENDOMETRIAL BIOPSY
What percentage of endometrial cancers is detected by in office EMB ?
• 83-98%
• Ability to detect cancer is improved in setting of global endometrial pathology and less
effective in setting of focal endometrial disease
If an adequate sample is obtained and findings are benign, do you need
additional assessment?
• No
If you are unable to obtain an adequate sample, what is the next step?
• TVUS can be performed
• Other options include sonohysterography or hysteroscopy D&C
• Most frequent cases are inability to access endometrial cavity and recovery of insufficient tissue for
evaluation
• Endocervical tissue alone does not indicate adequate endometrial sampling
TRANSVAGINAL ULTRASONOGRAPHY
How do you correctly measure endometrial thickness?
• Maximum anterior-posterior thickness of the endometrial echo on a long-axis
transvaginal view of the uterus

What endometrial thickness has a greater than 99% negative predictive


value for endometrial cancer?
• Less than or equal to 4mm
What are limitations of TVUS?
• An axial uterus, obesity, myomas, adenomyosis, or previous uterine surgery can
contribute to challenges assessing the endometrial thickness
• If unable to identify clear endometrial lining, can perform sonohysterography,
hysterography, or endometrial sampling
TRANSVAGINAL ULTRASONOGRAPHY

American College of Obstetricians & Gynecologists; ACOG Committee Opinion No. 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With
Postmenopausal Bleeding. Obstet Gynecol. 2018 May;131(5):e124-e129. doi: 10.1097/AOG.0000000000002631.
SOCIAL DETERMINANTS OF HEALTH
Obesity carries a relative risk of 2-5
for type I endometrial cancer.

Non-judgmental body-positive
counseling will help your therapeutic
relationship when discussing healthy
eating and exercise.

Remember to address healthy weight counseling at every well woman


visit!
Epic .Phrase
.BBonPMBcounseling
Description: Postmenopausal Bleeding Counseling

We discussed the differential diagnosis for postmenopausal bleeding including


vaginal or endometrial atrophy, polyps, fibroids, endometrial intraepithelial
neoplasia, or endometrial cancer. Given the potential risk of EIN or endometrial
cancer, I recommended prompt evaluation with EMB or TVUS. We reviewed
the risks and benefits of each assessment tool and with shared decision
making, we will proceed with *** for initial assessment.
CODING AND BILLING

• ICD-10 Codes
• 095.0
• Postmenopausal bleeding
• CPT Code
• 58100
• Endometrial sampling (biopsy) with or without endocervical sampling (biopsy) without
cervical dilation, any method (separate procedure)
EVIDENCE
• American College of Obstetricians & Gynecologists; ACOG Committee Opinion No. 734: The Role
of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With
Postmenopausal Bleeding. Obstet Gynecol. 2018 May;131(5):e124-e129. doi:
10.1097/AOG.0000000000002631.
• American College of Obstetricians & Gynecologists; Practice Bulletin No. 149: Endometrial
cancer. Obstet Gynecol. 2015 Apr;125(4):1006-26. doi: 10.1097/01.AOG.0000462977.61229.de.
• Dijkhuizen FP1, Mol BW, Brölmann HA, Heintz AP. The accuracy of endometrial sampling in the
diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer.
2000 Oct 15;89(8):1765-72.
• Savage A. Pearls of Exxcellence; Evaluation of Postmenopausal Vaginal Bleeding.Initial Approval
August 2014. Revised March 2019. Accessed July 2020. https://www.exxcellence.org/list-of-
pearls/evaluation-of-postmenopausal-vaginal-
bleeding/?categoryName=&searchTerms=postmenopausal+bleeding&featured=False&bookmark
ed=False&sortColumn=date&sortDirection=Descending

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