Introduction
Menopause is defined as the established cessation of menses succeeds by the loss of ovarian follicular activity.1 Menopause is derived from Greek word, Men means ‘Month’ and Pausis means ‘Cessation’. Conventionally menopause is not diagnosed until the individual has/ had 12 months of amenorrhea.2 The median age was calculated to be between 50-52 years, based on cross section studies.3
PMB has been defined by WHO, as an episode of bleeding in 12 months or more after the last menses. In general population, the incidence of postmenopausal bleeding is approximately 10% immediately after menopause and 5% in all menopausal women.4 Even without amenorrhea or irregularity, menstruation should be a subject of study and be investigated even after 55 years of age.5 Although postmenopausal bleeding is often associated with benign pathology, the possibility of having an underline malignancy makes it a sinister complaint requiring thorough clinical workup. Evidence has shown that early detection of cervical and endometrial cancer improves the cure rate and reduces mortality.6, 7 However unfortunately, like the cervical cancer there are no effective screening tests available for early detection of endometrial cancer.7 A classic study has categorized PMB as “Endometrial cancer until proven otherwise” which means that the PMB must always be investigated as this might be a symbol of endometrial carcinoma. Hence, the identification of postmenopausal bleeding in community settings provide an opportunity to detect these women at early stages of these cancers.
About 15% of cervical cancers are diagnosed in women over age 65. The 5-year survival rate for all women with cervical cancer is 66%. However, survival rates can vary by factors such as race, ethnicity, and age.8 Studies had shown that the range of cervical cancer varies from 10- 81% in all malignant causes of PMB.9 Since few studies describe the histological spectrum of lesions in entire genital tract hence this study was undertaken to examine the lesions in genital tract in cases of PMB.
Aims & Objectives
The aim of the study is to know the causes of postmenopausal bleeding based on Histopathological findings and the percentages of various benign, pre malignant and malignant lesions.
Materials and Methods
A prospective observational study conducted in the period July 2017-June 2019 at the Teerthanker Mahaveer Medical College and Research Centre, Moradabad, western UP, India, after approval by the Board of Studies and Ethical Committee in the Department of Obstetrics and Gynecology.
Inclusion criteria
All patients attending to gynaecological outpatient department with complaint of postmenopausal bleeding were taken in this study.
Exclusion criteria
Premature ovarian failure.
Patients on HRT.
Patients with obvious Decubitus ulcer with prolapsed uterus.
All cases of PMB undergone histopathological evaluation of endometrial carcinoma and cervical carcinoma. Samples were also taken from suspicious areas of vagina. The results were compiled, analysed and compaired to other studies.
Results
In our study, we included 53 women presenting to gynecology OPD of TMMC and RC, Moradabad, UP with complaint of postmenopausal bleeding. In my study incidence of postmenopausal bleeding is highest in age group of 46 – 50 years. Mean age being 55.85 years.
Table 1
Age distribution
|
Age groups |
Total cases (n=53) |
Percent |
|
41-45 years |
1 |
2% |
|
46-50 years |
19 |
36% |
|
51-55 years |
9 |
17% |
|
56-60years |
12 |
22% |
|
Above 61 years |
12 |
23% |
Table 2
Distribution of Histopathological findings in PMB cases
Table 3
HPE report on cervical biopsy
Table 4
Distribution of malignant & premalignant lesions from significant pathological cases of PMB
[i] Out of 26 cases (49.1%) premalignant & malignant causes of PMB, cervical malignancy accounts for 57.65%. Among cervical malignancy, 53.7% are carcinoma cervix and carcinoma in situ of cervix accounts for 3.8%.
Table 5
Correlation of age and Histopathological report
Discussion
PMB is a frequent and troubling symptom that can be associated with significant number of genital malignancy. Considering the gravidity significant pathologies as a cause of PMB, patients with PMB should be prioritized for early detection and management. In present era life expectancy has increased and women tend to live longer and many experience the postmenopausal phase. Postmenopausal bleeding is a very alarming sign that may be associated with cervical and uterine malignancies.
PMB is an important symptom of cervical and endometrial cancer patients to report. In addition to disturbing the normal routine itself, PMB can also be associated with increased morbidity due to underlying gynaecological or systemic pathology.
Endometrial sampling is harmless, rapid and simple procedures done in clinical setting.10
In our study, the maximum cases were between 46-50 years (36%) followed by above 61 years (23%) and 56-60years (22%). This can be due to instability of HPO axis in immediate postmenopausal state. This was similar to the study by Karmakar et al,11 31.60% were between 46-50 years and 3.20% were in between 66-70 years. In UbejaA et al12 29% belong to age group of 46-50 years and in Habib R et al13 63.8% belong to 45-55 years of age group. It was also observed that less number of patients reported with PMB at higher age, thus indicating an inverse relationship between age and age of occurrence of postmenopausal bleeding. (Table 1)
In the present study, malignant causes of PMB constitute 30.2% whereas benign causes were 69.8%. Ubeja A et al12 malignant cases accounts for 39% and benign 61%.(Table 2)
In our study, most common cause was atrophic endometrium (39.6%) Karmakar et al,11 reported 32% where as in Kothapally K et al,14 16.6%which was at par to Bani-Irshaid& Al-Sumadi A15 and Caspi E et al.16 The precise reason of bleeding from atrophic endometrium is not known. It is assumed to be due to vascular anatomy or local abnormal haemostatic mechanism.
In our study, Endometrial hyperplasia in 17% Karmakar et al11 showed endometrial hyperplasia in 21.2% and Kothapally K et al14 in 6.6% hyperplasia.
In our study endometrial Polyp accounts for 3.8% whereas in Kothapally K et al,14 endometrial polyps (15%). In endometrial polyp bleeding can be a result of injury to thin walled vein below the surface epithelium or thrombosis of the vessels.
Postmenopausal bleeding due to malignant and premalignant cases in present study was 49.1% (Table 4) which is comparable to Tyagi et al. 58.5%.17
Carcinoma cervix accounts for 26.4%, were as in Singh V et al9 it accounts for 46%. Other studies like Mallick A et al18 and Dawood et al19 contribute to 75.68% and 71.2% respectively.
Carcinoma Endometrium among 1.9%, the likelihood of endometrial cancer in a woman with PMB is approximately 9% in Irshaid B et al, 15 10% in Cheema et al20 & 9.28% in Mallick A et al.18 This result may be probably due to high parity in our population group as endometrial carcinoma is more common in nulligravida. As the association of Endometrial carcinoma is more with advancing age, late menopause thus this correlates with our study.
Present results were similar with studies of Nirupama et al,21 Kothapally et al14 and Dawood et al19 as in all these studies showed higher incidence of cervical malignancy than endometrial malignancy.
Carcinoma vagina among 1.9%, Sharma DD et al,22 2 out of 150 cases were diagnosed carcinoma vagina accounting for 0.67%.
Endometritis among (1.9%), In Kothapally K et al14 endometritis was reported in 2 cases out of 30 contributing to 6.6% of all causes of PMB.
Conclusion
Chances of cervical malignancy in a women with PMB is very high specially in a set up like ours because of poor sanitation, early marriage, early age of coitus, high parity, sexual promising quality, late reporting of any early signs and symptoms of underlying pathology and zero knowledge of HPV vaccination and lack of awareness leads to invasive carcinoma cervix even reporting at late stage Cervical cancer is a cancer that can be prevented because it has a long pre-invasive state and because the cervical cytology screening program can also detect the pre-invasive stage and because pre-invasive lesion treatment is effective.
