Postmenopausal genital bleeding

OURNAL

L u iz C a v a lc a n ti d e A lb u q u e rq u e N e to , M a ra ir G ra c io F e rre ira S a rto ri, E d m u n d C h a d a B a ra c a t, M a n o e l J o a o B a tis ta C a s te llo G ira o , G e ra ld o R o d rig u e s d e L im a

Postm enopausal genital bleeding

Division of Gynecology, Escola Paulista de Medic in a, Universidade Federal de Silo Paulo - Silo Paulo, Brazil

T he study w as conducted on 748 w om en w ho reported genital bleeding occurring at least one year after the last m enstruation. B enign causes w ere m ost frequent than m alignant causes. A m ong the benign causes, the m ost frequent w ere cervicitis (19,95% ), prolapsed uterus w ith decubitus ulcer (19,41 % ), dysfunctional hem orrhage (13,29% ) and endom etrial polyps (12,77% ). In the group of m alignant causes, cancer of the cervix w as the neoplasm m ost often detected (59,26% ); endom etrial cancer w as next, affecting 29,63% . T he cancer of the cervix/ cancer of the body ratio w as 2:1. In sum m ary, m any causes, both benign and m alignant, can provoke abnorm al postm enopausal bleeding. T hus, curettage of the uterus should be reserved for doubtful cases, i.e., in situations in w hich, after all non invasive m ethods of investigations h a v e been exhausted, the possibility of the occurrence of m alignant lesions still persist.

U N IT E R M S : M enopause. G enital bleeding.

IN T R O D U C T IO N

T

h e clim ateriu mfro m th e rep ro d u ctiv eis d efin edto th e n o n rep ro d u ctiv eas th e p erio d o f tran sitio nstate in w o m en 's liv es. T h is in terv al, w h ich v aries am o n g

in d iv id u als, is ch aracterized b y an ag in g p ro cess b ro u g h t

ab o u t b y th e reg ressi v e an ato m o fu n ctio n al ch an g es o f th e

o v aries.

G en ital b leed in g d u rin g th e p o stm en o p au sal p erio d

is an ev en t o f im p o rtan t im p licatio n s d u e to th e so m etim es

A d d r e s s fo r c o r r e s p o n d e n c e : L u iz C a v a lc a n ti d e A lb u q u e rq u e N e to

R u a N a p o le a o d e B a rro s , 715 - 7Q_{a n d a r - V . C le m e n tin o} S a o P a u lo - S P - B ra s il - C E P 0 4 0 2 3 -0 0 2

sev ere d iseases it reflects. T h is to p ic h as b een th e su b ject

o f in ten siv e stu d y , alth o u g h th ere is n o g en eral co n sen su s

ab o u t th e tim e b etw een m en o p au se an d th e b leed in g

ep iso d e an d its o rig in .

O n e y ear is co n sid ered to b e a su fficien t p erio d o f

tim e fo r th e stab ilizatio n o f th e en d o crin e ch an g es an d fo r

th e d efin itio n o f b leed in g as p o stm en o p au sal (4 ,

5 ,1 4 ,1 5 ,1 6 ,1 9 ,2 0 ,2 1 ). S o m e in v estig ato rs h av e in clu d ed

in th eir stu d ies o n ly w o m en w ith b leed in g o rig in atin g fro m

th e u teru s (2 ,9 ,1 2 ), w h ereas o th ers h av e also co n sid ered

b leed in g o rig in atin g fro m th e v ag in a, v u lv a o r u reth ra (1 7 ).

S o m e stu d ies h av e estim ated th at th e relatio n sh ip

b etw een p o stm en o p au sal b lo o d lo ss an d m alig n an t g en ital

n eo p lasm s v aries fro m ab o u t 6 3 to 9 0 % (8 ,2 0 ,2 1 ).

H o w ev er, M u ret (1 5 ) an d F ah n y (6 ) h av e rep o rted a less

freq u en t asso ciatio n o f 2 7 to 4 3 % .

O n th e b asis o f th ese fig u res, p o stm en o p au sal g en ital

b leed in g h as b een au to m atically related to m alig n an t

N E T O , L.C A ; S A R T O R I, M .G .F .; B A R A C A T , E .C .; G IR A o, M .J.B .C . & LIM A , G .R . -P ostm enopausal genital bleeding

g en ital n eo p lasm s. In d eed , th is h as b eco m e a stro n g ax io m

fo r sp ecialists.

H o w ev er, in th e lig h t o f n ew an d m o d ern k n o w led g e

o f th e p h y sio lo g y an d p ath o p h y sio lo g y o f th e rep ro d u ctiv e

tract an d o f w ell co n d u cted clin ical in v estig atio n s, th is

ad v erse p ictu re h as b een g rad u ally ch an g in g . A d eclin e in

th e in cid en ce o f m alig n an t cau ses h as b een d etected

sim u ltan eo u sly w ith an in crease in b en ig n cau ses.

T h u s, b leed in g is o b serv ed in th e p resen ce o f cerv ical

an d en d o m etrial p o ly p s, in cerv icitis, in sen ile co lp itis, in

h y p erp lastic en d o m etrial co n d itio n s, in ley o m io m as,

u reth ral caru n cles, d ecu b itu s u lcers d u e to a p ro lap sed

u teru s, v ag in al u lcers, an d also in o v arian tu m o rs w ith

h o rm o n e p ro d u ctio n . S elf-m ed icatio n as w ell as

in ap p ro p riate h o rm o n e p rescrip tio n rep resen t iatro g en ic

cau ses o f th e p ro b lem (3 ,7 ,1 1 ).It h as b een n o ted th at in all

stu d ies in a certain n u m b er o f cases ran g in g fro m 2 ,8 to

3 8 ,0 % , etio lo g y rem ain s th e o b scu re d esp ite th e co n cern

ab o u t ru lin g o u t m alig n an cy th ro u g h a carefu l clin ical an d

g y n eco lo g ical ex am in atio n , trip le o n co lo g ic

co lp o cy to lo g y , cy to lo g y o f m aterial fro m th e u terin e cav ity ,

en d o m etrial o r cerv ical b io p sy an d fractio n ated u terin e

cu rettag e (1 ,1 0 ,2 0 ).

T h e o b jectiv e o f th e p resen t stu d y w as to ev alu ate

p o stm en o p au sal g en ital h em o rrh ag e its v ario u s asp ects,

esp ecially in o rd er to d eterm in e its m o re freq u en t cau ses

an d its relatio n sh ip to clin ical p aram eters.

M A T E R I A L A N D M E T H O D

T h e stu d y w as co n d u cted o n 7 4 8 w o m en w h o

rep o rted g en ital b leed in g o ccu rrin g at least o n e fu ll y ear

after th e last m en stru atio n . T h e w o m en w ere selected fro m

a g ro u p o f 3 3 0 0 p atien ts o ld er th an 4 5 y ears an d m o re

th an o n e y ear in to m en o p au se, seen at th e D iv isio n o f

G y n eco lo g y , E sco la P au lista d e M ed icin a. T h u s, th e

in cid en ce o f th e b leed in g w as 2 1 ,8 % .

D ata related to ag e, race, m en stru al h isto ry ,

o b stetrical h isto ry , fin d in g s o f g en eral an d g y n eco lo g ical

p h y sical ex am in atio n , as w ell as cerv ico -v ag in al cy to lo g y ,

co lp o sco p y an d th e resu lts o f b io p sies o f su sp icio u s lesio n s

o f th e v u lv a, v ag in a an d cerv ix , w ere reco rd ed . F in ally ,

th e resu lts o f th e an ato m o p ath o lo g ic ex am in atio n o f th e

en d o m etriu m o b tain ed b y fractio n ated cu rettag e o f th e

u teru s w ere also reco rd ed .

R E S U L T S

F ig . 1 p resen ts th e ag e d istrib u tio n o f th e p atien ts

stu d ied , an d fig . 2 th e racial d istrib u tio n . F ig .3 sh o w s th at

m o st w o m en h ad m o re th an fiv e d eliv eries.

M en o p au se o ccu rred m o st freq u en tly b etw een 4 0

an d 4 9 y ears (tab le 1 ) an d th e in terv al b etw een

ex tem p o ran eo u s b leed in g an d m en o p au se w as m ain ly

m o re th an 1 0 y ears (tab le 2 ).

A s to etio lo g y , 5 1 ,6 5 % o f th e cau ses (3 7 6 cases) w ere

b en ig n , 3 3 ,3 8 % (2 4 3 cases) w ere m alig n an t, an d in o n ly

1 4 ,9 7 % (l0 9 cases) co u ld n o t b e d eterm in ed (F ig .4 ).

A m o n g th e b en ig n cau ses, th e m o st freq u en t w ere

cerv icitis an d d ecu b itu s u lcer in a p ro lap sed u teru s (1 9 ,9 5 %

an d 1 9 ,4 1 % , resp ectiv ely ). D y sfu n ctio n al b leed in g

d iag n o sed in th e ab sen ce o f o rg an ic lesio n s an d

en d o cerv ical p o ly p s w ere sim ilarly d istrib u ted (th eir

freq u en cies w ere 1 3 ,3 0 % an d 1 2 ,7 7 % , resp ectiv ely ). In

F ig u r e I - A g e D is t r ib u t io n

4 4 %

.4 5 -4 9

0 5 0 -5 9

0 6 0 -6 9

E i1 1 7 0 - 7 9

.> = 8 0

1 8 %

8 0 %

F ig u r e 2 - D is t r ib u t io n b y r a c e

2 % D W H I T E

BLACK

• O R I E N T A L

S a o P a u lo M e d ic a l J o u r n a l/ R P M 1 1 3 ( 5 ) : 9 8 7 - 9 9 1 , 1 9 9 5 N E T O , L . C A ; S A R T O R I , M . G . F . ; B A R A C A T , E . C . ; G I R . A . O , M . J . B . C . & L I M A , G . A .

989

500

400

300

200

100

o

F ig u re 3 - D istrib u tio n b y p a rity

418

DO

[1]1

lITJ2

E 13

.4

0 5 o r m o re

A g e (ye a rs)

u p to 3 9 4 0 -4 9 5 0 -5 9 6 0 o r m o re

T o ta l

T a b le I A g e o f m e n o p a u se

N

20

3 6 9 3 2 2 1 7 7 2 8

%

2 .7 5 5 0 .6 9 4 4 .2 3 2 .3 3 1 0 0 .0 0

contrast, endom etrial polyps w ere detected less frequently (4,25% ). S enile vulvovaginitis, w hich favors bleeding due to the fragility of the atrophic m ucosa, w as detected in 9,31 % of cases. U terine m yom a (4,25% ), urethral caruncles (3,72% ), endom etrial atrophy (3,19% ), endom etritis (2,66% ) and iatrogenic causes (3,72% ) w ere less frequent causes of the disorder. H orm one-producing ovarian tum ors and vaginal ulcers occurred in approxim ately 1% of cases (T able 3).

In the group of m alignant causes, cancer of the cervix w as the neoplasm m ost often detected, corresponding to 19,78% of all cases and to 59.26% of the m alignant causes in general. E ndom etrial cancer w as the next, affecting 9,89% of all cases and representing 29,63% of the m alignant causes (T able 4). T hus, the ratio of cancer of the cervix to cancer of the uterine body w as 2:I,as ilustrated in T able 5.

A m ong ovarian tum ors, five w ere granulosa cell tum ors and tw o w ere theca cell, corresponding to 2,88% of the total.

3 7 6

o

B e n ig n lZ JM a lig n a n t

[ill U n d e te rm in e d

F ig u re 4 - C a u se s o f p o stm e n o p a u sa l g e n ita l b le e d in g

T a b le 2

In te rva l b e tw e e n m e n o p a u se a n d th e e xte m p o ra n e o u s b le e d in g

In te rva l N %

1 -4 2 2 0 3 0 .2

5 -9 1 7 4 2 3 .9

> 1 0 3 3 4 4 5 .9

T o ta l 7 2 8 1 0 0 .0

L ess frequent w ere leiom yosarcom as (four cases, 0,54% ), carcinom a of the ovary (1,26% ) and neoplasm s of vulva and vagina (0,41 % ).

D IS C U S S IO N

In the present study, w e analyzed w om en w ith postm enopausal genital bleeding w ho w ere hospitalized or seen as outpatients, a fact that allow s a broader evaluation of etiology.

A s also reported by M athieu et al. (13), w e detected the highest frequency of bleeding in w om en aged 50 to 60 years and m ore than 10 years into m enopause.

T here w as a higher incidence of benign causes explaining the bleeding episodes, in agreem ent w ith date reported by Israel and W eber (9), R endina et al. (17) and P rocope (16).

C hronic cervicitis, detected in 75 cases, follow ed by decucitus ulcer in a prolapsed uterus (73 cases) w ere the m ajor causes of bleeding. In som e studies, the latter situation seem s to be the m ajor etiology (3, 20).

N E T O , L .G .A .; S A R T O R I, M .G .F .; B A R A G A T , E .G .; G IR A O , M .J.B .G . & L IM A , G .A . -P o stm e n o p a u sa l g e n ita l b le e d in g

Table 5

Cause correlation between the two periods studied

(1950-72 and 1973-86)

C e rv ic itis

P ro la p s e d u te ru s w ith d e c u b itu s u lc e r

D y s fu n c tio n a l h e m o rrh a g e

E n d o c e rv ic a l p o ly p

S e n ile v u lv o v a g in itis

U te rin e m y o m a

E n d o m e tria l p o ly p

U re th ra l c a ru n c le

Ia tro g e n ic c a u s e s

E n d o m e tria l a tro p h y

E n d o m e tritis

O v a ria n tu m o r

S e c re to ry e n d o m e triu m

N o n s p e c ific v a g in a l u lc e r

V u lv a r le u c o p la s ia

P e s s a ry

7 5 7 3

50

4 8 3 5 1 7 1 6 1 4 1 3 1 2 1 0 4 3 3 2 1

1 9 .9 5 1 9 .4 1 1 3 .3 0 1 2 .7 7 9 .3 1 4 .5 2 4 .2 5 3 .7 2 3 .4 6 3 .1 9 2 .6 6 1 .0 6 0 .8 0 0 .8 0 0 .5 3 0 .2 7

C a n c e r o f th e c e rv ix

C a n c e r o f th e e n d o m e triu m

F u n c tio n in g o v a ria n tu m o r

L e io m y o s a rc o m a o f th e u te ru s

C a n c e r o f th e o v a ry

C a n c e r o f th e v u lv a

C a n c e r o f th e v a g in a

M e la n o m a o f th e v a g in a

1 4 4

72

7 4 9 3 3 1

5 9 .2 6 2 9 .6 3 2 .8 8

1 .6 4 3 .7 0 1 .2 4 1 .2 4 0 .4 1

C a u s e s P e rio d

1 9 5 0 - 1 9 7 2 1 9 7 3 - 1 9 8 6

N % N %

I n s u m m a r y , m a n y c a u s e s , b o t h b e n i g n a n d m a l i g n a n t , c a n p r o v o k e a b n o r m a l p o s t m e n o p a u s a l g e n i t a l b l e e d i n g . A p r o p e r l y c o n d u c t e d p e l v i c e x a m i n a t i o n w i t h t h e a i d o f u l t r a s o n o g r a p h y c a n e x c l u d e p e l v i c d i s e a s e s s u c h a s o v a r i a n o r u t e r i n e t u m o r s . T h e p r o g e s t e r o n e t e s t , a l l i e d t o e n d o m e t r i a l c y t o l o g y a n d h y s t e r o s c o p y , c a n i d e n t i f y h y p e r p l a s i a s o r m a l i n a n t n e o p l a s m s i n t h e e n d o m e t r i u m . T h u s , c u r e t t a g e o f t h e u t e r u s s h o u l d b e r e s e r v e d f o r d o u b t f u l c a s e s , i .e ., i n s i t u a t i o n s i n w h i c h , a f t e r a l l n o n i v a s i v e m e t h o d s o f i n v e s t i g a t i o n h a v e b e e n e x h a u s t e d , t h e p o s s i b i l i t y o f t h e o c c u r r e n c e o f m a l i g n a n t l e s i o n s s t i l l p e r s i s t s

R i c h l y v a s c u l a r i z e d e n d o c e r v i c a l p o l y p s c a u s e d g e n i t a l b l e e d i n g i n 1 2 ,7 7 % o f t h e w o m e n s t u d i e d , a n i n c i d e n c e c l o s e t o t h a t r e p o r t e d b y J o n e s a n d C a n t o r ( 1 1 ) . E n d o m e t r i a l p o l y p s w e r e l e s s f r e q u e n t .

T h e i n c i d e n c e o f s e n i l e v u l v o v a g i n i t i s s h o u l d b e e m p h a s i z e d , i n v i e w o f t h e f a c t t h a t r u p t u r e p f t h e d e l i c a t e v e s s e l s o f t h e a t r o p h i c m u c o s a m a y o c c u r .

A m o n g t h e m a l i g n a n t c a u s e s o f b l e e d i n g , c e r v i c a l c a n c e r w a s t h e m o s t c o m m o n , f o l l o w e d b y e n d o m e t r i a l c a n c e r , r e s u l t i n g i n a 2 : 1 r a t i o .

L i t e r a t u r e h a s s h o w n a d e f i n i t e d e c l i n e i n t h e f r e q u e n c y o f c e r v i c a l c a n c e r , t o t h e p o i n t t h a t a p r o g r e s s i v e d e c r e a s e i n c e r v i c a l c a n c e r / c e r v i c a l b o d y r a t i o h a s b e e n o c c u r r i n g , w i t h a n i n v e r s i o n a c t u a l l y t a k i n g p l a c e . T h i s d u e t o t w o f a c t o r s : o n o n e h a n d , t h e w i d e a p p l i c a t i o n o f s c r e e n i n g m e t h o d s f o r t h e d e t e c t i o n o f p r e c u r s o r l e s i o n s , a n d o n t h e o t h e r t h e c o n c r e t e i n c r e a s e i n t h e i n c i d e n c e o f c a n c e r o f t h e e n d o m e t r i u m d u e t o t h e r e d u c t i o n o f n u m b e r o f b i r t h s , b e t t e r n u t r i t i o n a l c o n d i t i o n s ( o b e s i t y ) , t h e i n d i s c r i m i n a t e u s e o f e s t r o g e n s , a n d o t h e r s t i l l u n e x p l a i -n e d f a c t o r s ( 1 8 ) .

C a n c e r o f th e c e rv ix

C a n c e r o f th e b o d y

C e rv ix / b o d y ra tio

1 1 2 7 1 .3 4 4 5 2 8 .6 6

2 .4 8

3 2 5 6 .1 4 2 5 4 3 .8 6

1 .2 7

991

RESUMO

M a te ria l e M e to d o s : E s tu d a ra m -s e 7 4 8 m u lh e re s c o m q u e ix a d e s a n g ra m e n to g e n ita l a p 6 s u m a n o d e m e n o p a u s a . A s c a u s a s b e n ig n a s fo ra m m a is fre q u e n te s q u e a s m a lig n a s . R e s u lta d o s : D e n tre a s c a u s a s b e n ig n a s , a s m a is fre q u e n te s fo ra m c e rv ic ite (1 9 ,9 5 % ), u lc e ra e m d e c u b ito e m u te ro p ro la p s a d o (1 9 ,4 1 % ), h e m o rra g ia d is fu n c io n a l (1 3 ,2 9 % ) e p o lip o e n d o m e tria l (1 2 ,7 7 % ). N o g ru p o d a s c a u s a s m a lig n a s , 0 c a n c e r d e c o lo fo i a n e o p la s ia m a is d e te c ta d a (5 9 ,2 6 % ), s e g u id o p e lo c a n c e r e n d o m e tria l (2 9 ,6 3 % ). A re la c ;a o c a n c e r d o c o lo /c a n c e r d o c o rp o fo i 2 : 1 . C o n c lu s a o : E m re s u m o , m u ita s c a u s a s , ta n to b e n ig -n a s q u a -n to m a lig -n a s , p o d e m p ro v o c a r 0 s a n g ra m e n to g e n ita l n a p 6 s -m e n o p a u s a . D e s ta fo rm a , fic a ria a c u re ta g e m u te rin a re s e rv a d a p a ra o s c a s o s d u v id o s o s o u s e ja , e m s itu a c ;o e s n a s q u a is a p o s s ib ilid a d e d e le s o e s m a lig n a s a in d a p e rs is ta , a p 6 s a u tiliz a c ;a o d e m e to d o s d ia g n 6 s tic o s n a o in v a s iv o s .

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