Premenopausal, perimenopausal, and postmenopausal years–age 40 and over
Anovulatory bleeding accounts for about 90% of abnormal vaginal bleeding in this age group. However, bleeding should be considered to be from cancer until proven otherwise.
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History, physical examination and laboratory testing are indicated as described above. Menopausal symptoms, personal or family history of malignancy, and use of estrogen should be sought.
If a woman has a pelvic mass, an evaluation with ultrasonography, CT, and/or MRI is necessary.
In a perimenopausal or postmenopausal woman, amenorrhea preceding abnormal bleeding suggests endometrial cancer.
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Endometrial evaluation is necessary before treatment of abnormal vaginal bleeding.
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Before endometrial sampling, determination of endometrial thickness by transvaginal ultrasonography is useful because biopsy is often not required when the endometrium is less than 5 mm thick.
Treatment
Cystic hyperplasia or endometrial hyperplasia without cytologic atypia is treated with depo-medroxyprogesterone, 200 mg IM, then 100 to 200 mg IM every 3 to 4 weeks for 6 to 12 months. Endometrial hyperplasia requires repeat endometrial biopsy every 3 to 6 months.
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Atypical hyperplasia requires fractional dilation and curettage, followed by progestin therapy or hysterectomy.
If the patient’s endometrium is normal (or atrophic) and contraception is a concern, a low-dose oral contraceptive may be used. If contraception is not needed, estrogen replacement therapy should be prescribed.
Surgical management
Vaginal or abdominal hysterectomy is the most absolute curative treatment.
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Dilatation and curettage can be used only as a temporizing measure to stop bleeding.
Endometrial ablation and resection by laser, electrodiathermy “rollerball,” or excisional resection are alternatives to hysterectomy.
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