Postmenopausal Bleeding*

Abstract

During a two‐year period, 363 women with postmenopausal bleeding were studied. Included were women in whom the menses had been absent for one or more years and women treated with exogenous estrogens for at least one year. Endometrial tissue obtained by curettage was found to be hyperplastic (sometimes malignant) in a third of the cases, atrophic in a third, and proliferative in a third. Mechanisms of bleeding and sources of endogenous estrogens in postmenopausal women are discussed, as is the subject of steroidogenesis in patients unusually susceptible to endometrial carcinoma. In women with obesity, diabetes, or liver disease there is either an increased production rate of Δ4‐androstenedione or increased conversion of this hormone to estrone. The management of postmenopausal bleeding is discussed. The role of progesterone in preventing hyperplastic changes in the endometrium is emphasized. It is recommended that, during the climacteric, women receiving estrogen therapy and even those who are not, should be given progestogen for several cycles to see if withdrawal bleeding can be induced. If such bleeding does not occur, then progestogen therapy should be discontinued.

Reduced Incidence of Endometrial Cancer among Postmenopausal Women Treated with Progestogens*

“…Nulliparity, infertility, and anovulation are primary factors predisposing to endometrial cancer (10). In our previous study (15), a secretory endometrium was present in only 1.9 percent of patients with postmenopausal bleeding and rarely was concomitant with endometrial adenocarcinoma. Progesterone produces a more complete shedding of the endometrium, and progestogens can cause reversion of any degree of hyperplasia to normal endometrium in nearly all patients (Fig.…”

“…This risk can be markedly reduced by treating all patients who have any degree of hyperplasia with either progestogens or hysterectomy. In most patients, progestogens can restore any degree of hyperplastic endometrium to normal endometrium (10, 12, 13, 15, 16). Women with endometrial hyperplasia should be treated with either norethindrone (Norlutate 5 mg) or medroxyprogesterone (Provera 10 mg) for a minimum of 10 days each month.…”

Dysfunctional Uterine Bleeding

“…17 The percentage of patients with atrophy varies greatly among studies, probably reflecting different patient populations as well as variations in indication for biopsy and criteria for diagnosis of atrophy among different pathologists. [18][19][20][21][22][23] In many laboratories, atrophy is found in up to 50% of biopsy specimens taken for postmenopausal bleeding, and in one study 82% of cases of postmenopausal bleeding were attributable to atrophy. 20 Besides being common in postmenopausal patients, atrophic endometrium can occur in reproductive-age patients with premature ovarian failure, either idiopathic or due to radiation or chemotherapy for malignancies.…”