In postmenopausal patients, uterine bleeding may mean cancer.
When a postmenopausal woman presents with abnormal uterine bleeding, it’s essential to assess its etiology. In most women, endometrial polyps or fibroids are behind the problem, but in up to 10 percent of cases, endometrial or uterine cancer is the culprit.
In this video, Gina Mantia-Smaldone, MD, Associate Professor of Surgical Oncology, Fox Chase Cancer Center, outlines how physicians can evaluate and advise postmenopausal women who present with uterine bleeding.
Etiologies of postmenopausal bleeding
Patient evaluation and history
Examination overview: Biopsy and ultrasound
Staging endometrial cancer
Fox Chase offers a
Risk Assessment Program for individuals and families at risk for cancer and those with cancer, including breast, ovarian, gastrointestinal, endocrine, kidney, diffuse gastric, uterine and skin cancers. Our team of physicians, nurses and genetic counselors provides clinical and genetic evaluation and testing, screening and cancer risk-reduction services. To learn more, visit or call FoxChase.org/rap 877-627-9684. Hi my name is Gina Mantia Small Doan. I'm a G. Y. N. Oncologist at Fox Chase Cancer Center and I'm pleased to present the education on the go featuring abnormal year and bleeding and postmenopausal women. This is often a reason for referral to my practice and I feel the evaluation prior to coming to the offices important in order to rule out endometrium malignancy. While abnormal uterine bleeding is often a cause for alarm in both the patient. The provider. The majority of cases are actually due to benign ideologies and that can include endometrial polyps, genital atrophy or fibroids. In less than 10% of patients will be actually identify carcinoma or endometrial hyperplasia. But it's important to evaluate abnormal uterine bleeding and post menopausal women. To rule out malignancy when evaluating a patient with abnormal uterine bleeding. There are several key aspects of their um evaluation that need to be completed including a thorough history in a comprehensive physical exam, pelvic ultrasound perhaps obtaining a pap smear if that's not been done recently and then to also consider endometrial sampling which can be done either as an endometrial biopsy or D. N. C. Or dilation and curettage when performing a history of these patients. It's important to quantify the amount of bleeding. This can be done by asking questions regarding whether the bleeding is only noted with wiping or on pads and how many pads do the patients use in a typical 24 hour period. Quantifying the bleeding is important to identify if it is um something where the patient. Maybe he dynamically unstable. Okay getting a thorough gonn and menstrual history is important. Risk factors for abnormal bleeding could include prior hormone replacement therapy, use um known history of fibroids and is important in helping to determine the ideology for the bleeding sexual history. Is important to ask of the patient in the patients who have genital atrophy in history of recent intercourse preceding the event of bleeding may help to identify the ideology. Family history is important to ask, as women who have a family history of colon or uterine cancers may be raising a red flag for whether this patient has endometrial cancer as the source for their bleeding. It's also important to ask about medication, use tamoxifen or search terms can lead to an increased risk for endometrial hyperplasia or malignancy, hormone replacement therapy could lead to abnormal uterine bleeding and then anti coagulation. Uh coagulants such as um ela quis or aspirin or Coumadin may increase the risk for bleeding but also could impact how the patient is evaluated whether that needs to be done in the office versus the operating room. When patients present with abnormal uterine bleeding, a comprehensive physical exam is needed. It's important to examine all the superficial surfaces of the lower genital tract, including the vulva, the vagina, the cervix, the urethra and the anus to look for sources of bleeding. A bi manual examination is important to identify the uterine size and shape and this can help identify whether fibroids are present and contributing to the bleeding but it is also an important part of evaluating the patient's ability to have a minimally invasive surgery. If a hysterectomy is needed. A pap smear is a key part of physical examination to rule out cervical dysplasia or malignancy. And then at the time of a physical examination in women with abnormal uterine bleeding. An office endometrial biopsy may be discussed and performed after informed consent is attained. A pelvic ultrasound is a key part of the evaluation in which we are looking for structural ideologies that can contribute to abnormal uterine bleeding. We will evaluate the endometrial lining as depicted in this diagram. If the endometrial lining is greater than four, this would be a key reason to proceed with an endometrial biopsy or d. n. c. An endometrial lining could be thickened due to an endometrial polyp or hyperplasia or malignancy pelvic ultrasound can also identify other reasons for bleeding such as addendum aosis and lion may aromas. Um And so this would be something considered for patients with this. Um Chief complaint. Endometrial sampling ideally is going to help rule out malignancy or hyperplasia. Office endometrial biopsies allow us to do this biopsy without anesthesia to get a quick result and then move on to additional management if needed for cancer. An office endometrial biopsy. However may not be feasible in some patients due to patient discomfort or body habit tous or in the setting of cervical stenosis. In these patients dilation and curettage with hysteria. Skopje may be performed hysteria. A Skopje affords the opportunity of looking at the endometrial cavity, looking for polyps or signs of malignancy, the dilation and curettage that allows for a formal pathologic evaluation of this tissue. When women present for my opinion regarding their endometrial cancer management. We do see though while we look at the women who have abnormal uterine bleeding, only less than 10% will have malignancy In the patients who present with endometrial cancer and endometrial cancer, abnormal uterine bleeding may occur in up to 90% of these patients. So again, it's important to rule out malignancy in women with abnormal uterine bleeding and postmenopausal patients. But even in some patients with premenopausal abnormal bleeding, they may be at risk for endometrial cancer, especially in those who have unopposed estrogen exposure. And this can include women who have obesity, chronic an ovulation due to polycystic ovarian syndrome. Tamoxifen use nulla parity and early monarchy. Endometrial cancers on occasion can be diagnosed from an abnormal pap and these perhaps can sometimes identify admiral carcinoma or atypical glandular cells or endometrial cells that we do not expect to be present. And again, most of these patients will ultimately have a biopsy. Either done in the office or by D. N. C. That will confirm their diagnosis when patients present for endometrial cancer management. Typically the next step will be to surgically stage. Those patients the staging for endometrial cancer includes a total extra fashionable hysterectomy with bilateral south Pinghu for ectomy. We will often think about performing pelvic washings or site peritoneal cytology. Lymph node evaluation is a key part of this staging and this can be done either as a formal pelvic and periodic lymph node dissection versus sentinel lymph node biopsies In patients who may have high risk histology, ease of their endometrial cancer, such as women who have serious clear cell or carcinoma sarcoma says, Oh, mental biopsies and peritoneal biopsies may be important to evaluate for extra uterine disease. And ideally the goal of surgical staging is to achieve maximal side of reduction, especially in those women with high risk histology ease. We have known for about two decades plus that endometrial cancers have been um surgically staged. And the foremost lymph node staging was performed as a systematic regional resection of lymph nodes in the pelvic and the periodic region. However, over time we've learned that not all patients will have spread to these lymph nodes and this can lead to more comorbidities of lymphedema lymphocyte cells um and discomfort in the lower extremities. So over time we have actually borrowed technology from breast cancer staging where sentinel lymph node mapping is performed at the time of the surgical staging. There are blue dyes lymphomas or blue that can be injected into the cervix or I. C. G. That can be injected into the cervix. What we are doing is trying to identify the lymphatic spread from the uterus and identify the first one or two lymph nodes draining the cancer. To achieve the pathologic data that we need to stage their cancers while decreasing the morbidity to the patient. In the long term surgical staging is important as we know, it can impact the five year overall survival of the patients. The majority of cases will be diagnosed when the cancers are identified and confined to the uterus. However, with cancers that metastasize outside of the uterus, the five year survival starts to decline with women who have more advanced stage cancers having poor prognosis that is ultimately worse than some cases of ovarian cancers. So it's important when a patient presents for abnormal uterine bleeding management to get a thorough physical examination and nation, as well as endometrial sampling to identify those women who have endometrial cancers and hopefully get to a point where the surgical staging is performed and we identify cases where they're confined to the uterus. I want to thank you for the opportunity to talk about abnormal uterine bleeding and postmenopausal women. I feel this is a very important topic to educate patients about and we would be happy to see patients in referral for further work up