Obstetric & Gynaecology Malaysia


Menopause is defined as the permanent cessation of menstrual periods, determined retrospectively after a woman has experienced 12 months of amenorrhea without any other obvious pathologic or physiologic cause. It occurs at a median age of 51.4 years and is a reflection of complete  ovarian follicular depletion, with resulting hypoestrogenemia and high follicle-stimulating hormone (FSH) concentrations.

Perimenopausal period begin in the 40s. During this phase, hormone levels and the menstrual cycle begin to change. Perimenopause may last from ages 45years  to 55years, although the timing varies from person to person.

History — Important information that can be elicited from the patient's history includes the following:

●When did the bleeding start?

●Were there precipitating factors, such as trauma, intercourse, or intimate partner violence?

●What is the nature of the bleeding (eg, duration, quantity)?

●Are there any associated symptoms such as pain, fever, or changes in bladder or bowel function?

●Does the patient take any medications eg, hormone replacement therapy, anticoagulants or herbal or dietary supplements?

●Does the patient have a history of obesity or diabetes mellitus?

●Is there a family history of breast, colon, and endometrial cancer?


  • Structural abnormalities – Endometrial polyps and atrophy are the most common causes of PMB; leiomyomata and adenomyosis should not cause PMB in the absence of postmenopausal hormone therapy. While polyps and leiomyomata are typically benign, malignancy can occur.
  • Hyperplasia and carcinoma – Endometrial carcinoma is the cause of PMB in ~1 in 100 patients (~1%) overall. For patients who are not taking menopausal hormone therapy, the risk is higher (~ 12%). PMB is also common in patients with endometrial hyperplasia.
  • Medications – Uterine bleeding occurs in almost all patients receiving combined (ie, estrogen-progestin), cyclic hormone therapy; it is also common in the early months of continuous hormone therapy regimens. Other medications (eg, anticoagulants, antiplatelet therapies), herbal preparations, and dietary supplements may also result in uterine bleeding
  • Inflammation of adjacent organs (eg, diverticulitis) and infection (eg, endometritis) are less common causes of PMB.

Postmenopausal uterine bleeding (PMB), the frequency of endometrial pathology was as follows:

●Polyp (38%)

●Hypotrophy/atrophy (31%)

●Proliferative/secretory (15%)

●Carcinoma (1%)

●Fibroid (5%)

●Hyperplasia without atypia (2%)

●Hyperplasia with atypia (<1%)

Endometrial polyps are localized hyperplastic overgrowths of endometrial glands and stroma that are a common cause of perimenopausal and early postmenopausal bleeding. Growth of polyps can be stimulated by estrogen therapy or tamoxifen. While the majority of polyps are benign=non cancerous, the incidence of malignant or hyperplastic polyps is higher in postmenopausal compared with premenopausal patients

Endometrial atrophy . The hypoestrogenic changes that occur in menopause cause atrophy of the endometrium and vagina. In the uterus, the collapsed atrophic endometrial surfaces contain little or no fluid to prevent intracavitary friction. This results in microerosions of the surface epithelium and a subsequent chronic inflammatory reaction (chronic endometritis), which is prone to light bleeding or spotting.

Endometrial hyperplasia (EH; with or without atypia) may progress to, or coexist with, endometrial carcinoma, and often presents as uterine bleeding. EH is most common in perimenopausal or early postmenopausal patients; risk factors for EH are similar to those for endometrial carcinoma

Endometrial carcinoma is among the most common cancer in females, after breast and cervical cancer; it is more common in postmenopausal compared with premenopausal patients and presents with vaginal bleeding in most patients . Increasing age, obesity, nulliparity, and diabetes mellitus are also associated with increased rates of endometrial carcinoma.

Inflammation or infection from adjacent organs, such as diverticulitis, can occasionally cause a corresponding inflammation of the female upper genital tract. Similarly, a ruptured sigmoid diverticulum may fistulize into the uterus and present as uterine bleeding, discharge, and endometritis. Endometritis from bacterial vaginosis is not uncommon cause of PMB in diabetic patients. Genital tuberculosis may also present as PMB.

Either endometrial sampling or transvaginal ultrasound (TVS) is used as the initial test for evaluating the endometrium. Endometrial biopsy is often preferred because it results in a tissue diagnosis and has a high sensitivity, low complication rate, and low cost.

Proliferative/secretory endometrium is not a form of endometrial hyperplasia but suggests active estradiol secretion (eg, by adipose tissue; or an estrogen-producing tumor) or exposure to exogenous estrogens and should be evaluated further. 

For patients with recurrent or persistent bleeding, further diagnostic e(eg, dilation and curettage with hysteroscopy) is ivaluation ndicated. Persistent bleeding can be a sign of endometrial carcinoma, even in the setting of a "benign" endometrial biopsy or thin (ie, ≤4 mm) endometrial stripe on TVS.

In postmenopausal patients, uterine bleeding is usually light and self-limited, and treatment is usually unnecessary once endometrial carcinoma (or premalignant histology) has been excluded.  However, further diagnostic evaluation with dilation and curettage with hysteroscopy  is indicated for recurrent or persistent bleeding as this can be a sign of endometrial carcinoma.