My patient, a postmenopausal woman, reports irregular vaginal bleeding. How is postmenopausal bleeding diagnosed and treated?-A.K., N.C.
Margaret McGill, RN, CNM, MN, replies: Because vaginal bleeding that occurs after menopause is a common warning sign of endometrial cancer, it should never be ignored. (Irregular bleeding may be normal in younger women because of hormonal fluctuations.)
Besides endometrial cancer, possible causes of postmenopausal bleeding include genital trauma, friable vulvar lesions, prescription or nonprescription hormonal therapies, overgrowth of the uterine lining, uterine or cervical polyps, or cancer of the cervix, fallopian tube, or ovary. Bleeding from hemorrhoids also can be mistaken by the patient for vaginal bleeding.
The health care provider may order a pelvic ultrasound to determine the thickness of the uterine lining and to look for ovarian or uterine tumors. She'll also perform an endometrial biopsy by introducing a flexible cannula into the uterus and suctioning fluid and cells. She may obtain a tissue specimen from the cervix's inner lining at the same time. In the lab, biopsy specimens are examined for abnormal cells. An alternative procedure for obtaining biopsy specimens is dilation and curettage.
Depending on the cause of bleeding, treatment ranges from hormone therapy to treat friable tissue to surgery to remove lesions. Surgical removal of the uterus, tubes, or ovaries may be indicated if cancer is diagnosed.
Endometrial cancer, the most common reproductive tract cancer in women, most often affects women in their 50s and 60s. Besides age, other factors associated with endometrial cancer are obesity, nulliparity, diabetes, hypertension, polycystic ovary syndrome, late menopause, and white race.
Estrogen therapy may cause endometrial cancer, especially when given without progesterone to women who haven't had a hysterectomy. Other drugs that have estrogenic actions, such as tamoxifen, have also been implicated.
Make sure your patient sees a gynecologist for further diagnosis and treatment.
Margaret McGill is a certified nurse-midwife and assistant professor of nursing at Vanderbilt University School of Nursing in Nashville, Tenn. Clinical Queries is coordinated by Joan E. King, RN,C, ACNP, ANP, PhD, program director for the acute care nurse practitioner program at Vanderbilt University.