In this era, life expectancy of women has increased hence, many will experience postmenopausal period. Genital tract bleeding is an alarming symptom in this age group. The episodes of genital tract bleeding vary with clear span i.e. the period between cessation of menses and onset of bleeding per vagina. The clear span is divided into three clear phases; first phase between 6-12 months, second phase between 12-24 months and third phase over 24 months. It is not always possible to assign pathologic cause with certainty in postmenopausal bleeding (PMB). The dictum is “Postmenopausal bleeding indicates malignancy until proved otherwise”.

Thus the aims and objectives of this study were:
1) To ascertain aetiological factors of postmenopausal bleeding.
2) To investigate the incidence of malignancy in relation to the clear span.

Material and Methods

This was a retrospective and prospective study, conducted over a period of 44 months between January 1996 and September 2000 in surgical pathology department. A total of 108 consecutive cases who presented clinically with postmenopausal bleeding were selected. All the patients gave history of genital tract bleeding varying from spotting per vagina (pv), scant flow, moderate to profuse bleeding or post coital bleeding, appearing six months and thereafter after menopause.

The age of the patient and clear span was recorded. None of the women were on hormone replacement therapy. The specimens received varied from endometrial biopsy/curettage (32), cervical biopsy (54), to hysterectomies (30). The slides were reviewed and reclassified using current pathological criteria. In 4 cases, the endometrial biopsy was inadequate and therefore these cases were excluded from the study. Thus 104 cases formed the study sample.

The endometrial specimens were divided into following histological categories: 1) endometrial atrophy 2) proliferative phase (PP) 3) endometrial polyp 4) endometrial hyperplasia and 5) endometrial carcinoma. Endocervical lesions were classified as inflammatory, polyp, dysplasia and carcinoma.

Of the 104 cases, 9 biopsies were followed by hysterectomy of which 3 were cases of cervical cancer and 2 cases each of endometrial polyp, hyperplasia and endometrial carcinoma.

Results

Majority of patients presenting with postmenopausal bleeding was observed in the third phase of clear span, as seen in Table 1.

Benign lesions in endometrium were classified as functional and organic as shown in Table 2. There was almost equal distribution of cases in both categories.

The interval between preceding operation and appearance of symptoms is shown in Table 1. All patients complained of pain and swelling along the scar with cyclical increase during menses. One patient had ulcerative superficial lesion on the perineum. Associated symptoms like pain in abdomen and menorrhagia was seen in two patients, while one patient complain of dyspareunia.

Discussion

Genital tract bleeding in postmenopausal women is a sign of underlying pathologic condition. The clear span was divided into three phases, it was observed that malignancy and dysplasia were predominantly seen in third phase (41%) as compared to that observed in the first and second phase of clear span (9%). The incidence of malignancy increases with delay in presentation of this symptom. The peak incidence of malignancy was observed in the age group of 56-65 years. The incidence of postmenopausal bleeding decreased with increasing age, however probability of malignancy as underlying cause increased.

In this study, endometrium contributed to 50% of the causes of PMB. The atrophic endometrium inclusive of senile cystic atrophy was the predominant finding (16.3%), which is comparable to the observations of Lidor et al.3 The exact cause of bleeding from atrophic endometrium is not known. It is postulated to be due to anatomic vascular variations or local abnormal haemostatic mechanism.2 Speert considers that thin walled veins superficial to expanding cystic gland make the vessel vulnerable to injury especially if cyst ruptures.4

The incidence of proliferative endometrium is 8.6% in this study that is higher than previous studies.5 Majority of cases were seen in third phase of clear span. The occurrence of proliferative endometrium could be due to fluctuating levels of progesterone from follicular remnants, the effect of which persists even upto 15 years after cessation of menses.6 Endometrial polyp constitutes 2.8% in this study.

Endometrial hyperplasia with or without atypia is considered to be precursor of carcinoma.7 and was the second frequent cause of PMB in the present study (13.46%). This incidence is higher as compared to previous studies.8 The basis is persistent oestrogenic stimulus, as from adipose tissue, which is a major conversion site of androsteniodione to oestrone. The other causes of oestrogenic stimulus can be adrenals, residual ovarian stromal tissue, functioning ovarian tumour or exogenous source.5

The incidence of endometrial adenocarcinoma in this study is 9.6%, which is similar to studies reported in literature.5,8

The cervical lesions contributed to 47% of PMB. The carcinoma of cervix and dysplasia contributes to 42% thus accounting for more than two-thirds of cases. Other cervical lesions include infective and inflammatory conditions like endocervicitis (2.8%), cervical ulcer (0.96%), endocervical polyp (0.96%). The cervix and vagina are more susceptible to trauma and infection in postmenopausal age group, because of atrophic changes in cervix and with change in vaginal pH. There was a single case of ovarian granulosa cell tumour, which showed endometrial hyperplasia responsible for PMB, which is a known target cell phenomenon of functional ovarian tumours.

Conclusion

1. Postmenopausal bleeding is a symptom not to be underestimated.
2. The results showed that malignant causes were the most common while functional and organic causes had equal distribution.
3. Among the malignant causes, cervical carcinoma accounts for 39% in this study of postmenopausal bleeding. This high incidence may point to ineffectiveness of existing surveillance and the need for more public awareness to integrate routine gynaec-pap screening as a routine method.
4. The uterine causes of bleeding in this study show atrophic endometrium as most frequent cause (16%) followed by endometrial hyperplasia (13%).
5. This indicates malignancy cannot be ruled out until proved otherwise and justifies a thorough evaluation of patients with this symptom along with histopathological confirmation.

References

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