Postmenopausal genital bleeding

The study was conducted on 748 women who reported genital bleeding occurring at least one year after the last menstruation. Benign causes were most frequent than malignant causes. Among the benign causes, the most frequent were cervicitis (19,95%), prolapsed uterus with decubitus ulcer (19,41%), dysfunctional hemorrhage (13,29%) and endometrial polyps (12,77%). In the group of malignant causes, cancer of the cervix was the neoplasm most often detected (59,26%); endometrial cancer was next, affecting 29,63%. The cancer of the cervix/ cancer of the body ratio was 2:1. In summary, many causes, both benign and malignant, can provoke abnormal postmenopausal bleeding. Thus, curettage of the uterus should be reserved for doubtful cases, i.e., in situations in which, after all non invasive methods of investigations have been exhausted, the possibility of the occurrence of malignant lesions still persist.


INTRODUCTION
T he climaterium is defined as the period of transition from the reproductive to the nonreproductive state in women's lives.This interval, which varies among individuals, is characterized by an aging process brought about by the regressi ve anatomofunctional changes of the ovaries.
Genital bleeding during the postmenopausal period is an event of important implications due to the sometimes Address for correspondence: Luiz Cavalcanti de Albuquerque Neto Rua Napoleao de Barros, 715 -7 Q andar -V.Clementino Sao Paulo -SP -Brasil -CEP 04023-002 severe diseases it reflects.This topic has been the subject of intensive study, although there is no general consensus about the time between menopause and the bleeding episode and its origin.
One year is considered to be a sufficient period of time for the stabilization of the endocrine changes and for the definition of bleeding as postmenopausal (4,5,14,15,16,19,20,21).Some investigators have included in their studies only women with bleeding originating from the uterus (2,9,12), whereas others have also considered bleeding originating from the vagina, vulva or urethra (17).
Some studies have estimated that the relationship between postmenopausal blood loss and malignant genital neoplasms varies from about 63 to 90% (8,20,21).However, Muret (15) and Fahny (6) have reported a less frequent association of 27 to 43%.
On the basis of these figures, postmenopausal genital bleeding has been automatically related to malignant genital neoplasms.Indeed, this has become a strong axiom for specialists.However, in the light of new and modern knowledge of the physiology and pathophysiology of the reproductive tract and of well conducted clinical investigations, this adverse picture has been gradually changing.A decline in the incidence of malignant causes has been detected simultaneously with an increase in benign causes.Thus, bleeding is observed in the presence of cervical and endometrial polyps, in cervicitis, in senile colpitis, in hyperplastic endometrial conditions, in leyomiomas, urethral caruncles, decubitus ulcers due to a prolapsed uterus, vaginal ulcers, and also in ovarian tumors with hormone production.
Self-medication as well as inappropriate hormone prescription represent iatrogenic causes of the problem (3,7,11 ).It has been noted that in all studies in a certain number of cases ranging from 2,8 to 38,0%, etiology remains the obscure despite the concern about ruling out malignancy through a careful clinical and gynecological examination, triple oncologic colpocytology, cytology of material from the uterine cavity, endometrial or cervical biopsy and fractionated uterine curettage (1,10,20).
The objective of the present study was to evaluate postmenopausal genital hemorrhage its various aspects, especially in order to determine its more frequent causes and its relationship to clinical parameters.

MATERIAL AND METHOD
The study was conducted on 748 women who reported genital bleeding occurring at least one full year after the last menstruation.The women were selected from a group of 3300 patients older than 45 years and more than one year into menopause, seen at the Division of Gynecology, Escola Paulista de Medicina.Thus, the incidence of the bleeding was 21,8%.
Data related to age, race, menstrual history, obstetrical history, findings of general and gynecological physical examination, as well as cervico-vaginal cytology, colposcopy and the results of biopsies of suspicious lesions of the vulva, vagina and cervix, were recorded.Finally, the results of the anatomopathologic examination of the endometrium obtained by fractionated curettage of the uterus were also recorded.

RESULTS
Fig. 1 presents the age distribution of the patients studied, and fig. 2 the racial distribution.Fig. 3 shows that most women had more than five deliveries.
Menopause occurred most frequently between 40 and 49 years (table 1) and the interval between extemporaneous bleeding and menopause was mainly more than 10 years (table 2).
In the group of malignant causes, cancer of the cervix was the neoplasm most often detected, corresponding to 19,78% of all cases and to 59.26% of the malignant causes in general.Endometrial cancer was the next, affecting 9,89% of all cases and representing 29,63% of the malignant causes (Table 4).Thus, the ratio of cancer of the cervix to cancer of the uterine body was 2: I, as ilustrated in Table 5.

DISCUSSION
In the present study, we analyzed women with postmenopausal genital bleeding who were hospitalized or seen as outpatients, a fact that allows a broader evaluation of etiology.
As also reported by Mathieu et al. (13), we detected the highest frequency of bleeding in women aged 50 to 60 years and more than 10 years into menopause.
There was a higher incidence of benign causes explaining the bleeding episodes, in agreement with date reported by Israel and Weber (9), Rendina et al. (17) and Procope (16).
Chronic cervicitis, detected in 75 cases, followed by decucitus ulcer in a prolapsed uterus (73 cases) were the major causes of bleeding.In some studies, the latter situation seems to be the major etiology (3,20).In summary, many causes, both benign and malignant, can provoke abnormal postmenopausal genital bleeding.A properly conducted pelvic examination with the aid of ultrasonography can exclude pel vic diseases such as ovarian or uterine tumors.The progesterone test, allied to endometrial cytology and hysteroscopy, can identify hyperplasias or malinant neoplasms in the endometrium.Thus, curettage of the uterus should be reserved for doubtful cases, i.e., in situations in which, after all nonivasive methods of investigation have been exhausted, the possibility of the occurrence of malignant lesions still persists Richly vascularized endocervical polyps caused genital bleeding in 12,77% of the women studied, an incidence close to that reported by Jones and Cantor (11).Endometrial polyps were less frequent.
The incidence of senile vulvovaginitis should be emphasized, in view of the fact that rupture pf the delicate vessels of the atrophic mucosa may occur.
Among the malignant causes of bleeding, cervical cancer was the most common, followed by endometrial cancer, resulting in a 2: 1 ratio.
Literature has shown a definite decline in the frequency of cervical cancer, to the point that a progressive decrease in cervical cancer/ cervical body ratio has been occurring, with an inversion actually taking place.This due to two factors: on one hand, the wide application of screening methods for the detection of precursor lesions, and on the other the concrete increase in the incidence of cancer of the endometrium due to the reduction of number of births, better nutritional conditions (obesity), the indiscriminate use of estrogens, and other still unexplained factors (18).

Figure
Figure I -Age Distribution