Ambulatory Report – Post-Menopausal Vaginal Bleed – 9.21.16

Thanks to Jasmine Rassiwala for presenting a case of a 52 yo post-menopausal female with a history of hypertension, diabetes, and chronic pain, presenting with 3 days of heavy vaginal bleeding after MVA.
  • SSRIs & Bleeding!
    • Studied in case reports since 1990, as of 2010 there have been 34 observational epidemiologist studies showing that SSRIs moderately increase risk of bleeding
    • UGIB odds ratio pooled from 14 studies
      • SSRI —> OR = 1.8
      • NSAID —> OR = 3.3
      • Combined SSRI + NSAID —> OR 9.1
    • SSRIs & NSAIDs are NOT benign and have significant bleed risk!
  • Post-Menopausal Uterine Bleeding Diagnostic Evaluation (of women NOT on hormone replacement therapy)
    • Must EXCLUDE Malignancy
    • History Key Questions
      • When did the bleeding start?
      • Any precipitating factors or trauma?
      • What’s the nature of the bleeding (timing, duration, postcoital, quantity)
      • Associated sx?  (ie. pain, fever, bladder or bowel function changes)
      • Med Hx & Medications (ie. hormones or anticoagulants)
      • Any soy-containing or dietary supplements?
      • Fix of breast, colon, or endometrial CA?
    • Physical Exam
      • External & Internal GU exam
    • Evaluate the Endometrium 
      • Either endometrial biopsy or transvaginal ultrasound can be used as an initial test for evaluating the endometrium.
      • Transvaginal Ultrasound recommended if:
        • can’t tolerate a endometrial biopsy OR if evaluation of uterine pathology (ie. polyp, leiomyoma) or of adnexa indicated
        • can r/o endometrial CA if u/s in postmen women is thin (<4mm) with a homogenous endometrium
      • Endometrial Biopsy recommended as first line
        • Definitely must get EMB if:
          • endometrial lining thicker than 4mm
          • endometrium shows diffuse or focal increased echogenicity (ie. heterogeneity)
          • endometrium not adequately visualized
          • woman has persistent bleeding
    • Must get Cervical Cancer Screening!

Evernote Link: https://www.evernote.com/l/ADVnFe3-lyBP8qoZLcv6gTkc7_h2X1DhYq4

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