Diseases, Disorders information

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Perimenopausal bleeding: this is usually physiologic and self limited. These menstrual disturbances are usually the rule as I’ve said earlier, but we must evaluate them to rule out cancer. Usually they have ovulatory then anovulatory cycles, or several anovulatory cycles in a row, get a little endometrial hyperplasia or an endometrial polyp, or have other lesions such as submucous fibroids or something like that. So you must evaluate these and rule out cancer. I had a patient earlier this year who was only 47 that was having menstrual irregularities. And we biopsied and biopsied and didn’t get anything and couldn’t control them. She’d been tried on various hormonal therapies prior to coming to see me. We ended up doing a hysterectomy and when we opened the uterine specimen she had 50% myometrial invasion by an endometrial carcinoma. So it does happen in younger people. But it’s unusual.
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Postmenopausal bleeding is never physiologic. Fifteen to twenty percent of them represent cancer. The etiology is unopposed estrogens, or peripheral conversion in fatty tissue to estrone. Sometimes they are given hormone replacement or exogenous estrogen for years at a time without any progestin to counteract it. Or they have a uterine or ovarian tumor. I’ve diagnosed several ovarian cancers by postmenopausal bleeding. The evaluation of the endometrium is mandatory in these patients. You must do something to evaluate them to rule out a cancer. And that’s in the postmenopausal. How do we evaluate them? Of course, our history, physical and laboratory are your beginnings. You can do non-invasive tests and invasive tests. If I have young patients who are having menometrorrhagia and we suspect they are becoming anemic, a CBC is helpful. Oftentimes you may want to do some bleeding studies, because up to 17% of patients in some studies have been shown to have a bleeding diaphysis that was unknown by the physician and unknown by the patient. So you might keep that in the back of your mind that you might want to do a PTT and a PT and a platelet count. I get a history about the number of pads and tampons, or both if they are using both. Some patients are flowing so heavily they are losing work because they are embarrassed to go out of the house. They are wearing tampons and pads and flooding through them in an hourly pattern. So how often are they changed. If the patient can’t remember the numbers, what I start asking them then is, “Okay, are you using pads and tampons?” If they are using both and they can’t remember how many, then I ask them “How many boxes do you use during a menstrual cycle?” They can remember boxes. Then I ask them, “Okay, how many are in the box that you buy?” And you can get a pretty accurate count that way of how many pads and tampons they are using. Ask them whether they are soaked or not, if they are flooding through them are they also flooding onto their clothes, are they passing any clots, how big are the clots - and most of them are passing quarter to half-dollar size clots. How long has this been going on, is this the same as usual for them or have their periods been getting longer, are they getting heavier days of flow, and you’d be surprised at how many patients will tell me, “Oh, I’ve been doing this now for two or three years. And they’ve been putting up with it for that long.
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Their heaviest days … usually most of them will start out with a fairly normal bleed and then all of a sudden it gets real heavy and passes clots and then after a couple of days they will get a little bit better. Then I find out, have we had any previous infections such as things I would suspect for PID or Chlamydia which may cause bleeding and problems. Have they had any treatments recently, are they taking any hormones or have they had any trauma. Then a history of any blood dyscrasias. Up to 17% can be involved. Any medications? Patients don’t think of aspirin and ibuprofen as being medications, or any of the other nonsteroidal antiinflammatories that will cause bleeding problems. In fact, it’s amazing the number of patients that I talk to that don’t think birth control pills are medications. So you have to ask them specifically about that.