1. The postmenopausal bleeding (PMB)
is defined as bleeding from the genital tract , one or more years following the cessation of menses .

2. Aetiology
Genital and extra-genital pathology , both benign and malignant
12% of women with PMB have a primary or secondary malignancy
88% of women with PMB will have a benign cause
Extra-genital pathology is found in 4%

3. Hyperplasia
Simple ( cystic gland ) without atypia 1% %Complex without atypia ( adenomatous) 3
Hyperplasia with atypia 8-29%

4. Pathophysiology : *Atrophic endometrium : chronic endometritis ,
endometrial vascular disease ,
rupture of endometrial cysts , and
venous bleeding following the blockage of venules by overdistended endometrial glands .

5. Clinical Assessment :
History
Examination :
:Investigations

6. :Investigations Dilatation and Curettage Outpatient endometrial Biopsy
Hysteroscopy
Three-Dimensional Scanning
Doppler and Colour flow Imaging
Ultrasound

7. Special Situations :
Hormone replacement therapy
Tamoxifen

8. Management
Atrophic vagnitis :HRT (Topical oestrogen cream, oestrogen pessaries , oestrogen ring pessaries ).
Cervical polyp: Remove via speculum examination using polyp forceps .
Endometrial polyp : Remove under direct visualization at hysteroscopy .
Simple hyperplasia :Progesteron :oral preparations or LNG-IUS (Mirena) .

9. Management
Complex hyperplasia : Progesteron :oral preparations or LNG-IUS (Mirena) .
Atypical hyperplasia :Total abdominal hysterectomy as significant risk of progression to malignancy .
Endometrial cancer: Total abdominal hysterectomy +BSO +washing ±adjuvant therapy .
   

10. Hysteroscopy Advantages :
Direct inspection of endometrial &directed biopsy can be taken .
Detect 95% of intrauterine abnormality.
Sensitive in identifying uterine polyp or submucous fibroid (that are difficult to determine by U/S examination).
Can be used as outpatient procedure& treatment be given in the same session can

11. Hysteroscopy Complications : Fluid overload . Hyponatremia .
Uterine perforation.
Infection .
Cervical truma .