Louw, James T

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South African Medical Journal: Suid-Afrikaanse Tydskrif vir GeneeskundeCape Town, 10 October 1959General Practice SeriesVolume 33 No. 41 Deel 33 Kaapstad, 10 Oktober 1959POST-MENOPAUSAL BLEEDINGlAMES T. Louw, CH.M., ER.CO.G.Professor of Obstetrics and Gynaecology, University of Cape Town, and Cape Provincial AdministralionIn life it is essential to be clear in thought. In order to attainthis happy yet difficult mental state neat definitions are neces-sarY. Once a fixed point is established the course set by thecompass of discussion will be clear cut and will be a relativelyeasy one to follow. Although the word 'menopause' means'the last period', as opposed to 'the climacteric' which denotes'a critical period or change' (the latter :-eferring to the wholephysical and psychological period of involutionary change),by common usage the two terms, medically speaking, havebecome synonymous.Any bleeding after the menopause-no matter whether theperiods ceased normally or through artificial measures-is aserious symptom warranting a careful history with diligentclinical examination and special investigations. Post-meno-pausal bleeding must always be considered as cancerous inorigin until proved otherwise. This cannot be stressed suffi-ciently. It may well be wise to make a slight diversion fromthe topic of discussion and to include another principle, viz.that excessive or irregular bleeding at the time ofThe climactericis abnormal and must always be regarded as abnormal. Ab-normal bleeding must never be considered a normal pheno-menon. It demands pathological explanation. As cancer isdetected in about 40% of patients complaining of post-menopausal haemorrhage it may, for purposes of clearunderstanding, be as well to consider the causes of thisbleeding. They may fairly readily be classified as follows:CAUSES OF POST-MENOPAUSAL BLEEDING1. Neoplasms(a) MalignantUterinei. Cancer, cervixEctocervicalEndocervicalii. Cancer, endometriumiii. Uterine sarcomaExtra-uterineiv. Ovarian (functioning and non-functioning)v. Cancer, vaginavi. Cancer, vulvavii. Spread from cancer, bladder or rectumviii. Sarcoma of the above organsix. Cancer, Fallopian tube(b) Benign:i. Fibroidii. Ovarianiii. Benign tumour of vagina or vulvaiv. Cervical polypus2. Hormonal: OestrogenHyper-i. Therapyii. Secretory tumouriii. Rejuvenescence of ovariesHypo-i. Senile vaginitisii. Senile endometritis3. lnflammationsAcuteChronic4. TraumaProlapseDenudation of exposed cervix and vaginaPressure sloughing due to corrective pessaryRapeAccident. 5. Extra-genital (difficult or impossible for the patient to localizethe origin of the bleeding)(a) Urinary tract lesionsCarunclesOther causes of haematuria(b) Bowel lesionsCauses of fresh bleeding from and through the anusCancer of the cervix uteri is responsible for the majority ofthe deaths occuring in the gynaecological wards of the GrooteS~huur Hospital, Cape Town. It is a disease most commonlyfound in women of ages ranging between 40 and 45, and relat-ively often in the post-menopausal age. It is easily recognized inmost instances, though recognition cannot take place withouta vaginal examination, i.e. both palpation and the insertionof a speculum for inspecting the cervix. The effort required isminimal and the reward of recognizing an early cancer is sogreat that no one may venture to prescribe before the trueclinical assessment has been completed. Under no circum-stances should an erosion of the post-menopausal cervix becauterized before an adequate biopsy has been taken and thehistological diagnosis of the lesion established.Even if the appearance of the ectocervical epithelium isnormal, a cancer may yet be lurking in the endocervical canal.Further exploration therefore becomes essential. It is also tobe emphasized that, if by some misadventure a previoussubtotal hysterectomy has been performed, cancer of thecervical stump must always be kept in mind when subsequentbleeding takes place.Endometrial cancer. The clinical finding of an enlargeduterus for her age in a patient complaining of bleeding afterthe menopause is significant. However, the size of the uterusis often totally unrelated to the cancer it may harbour.Therefore, all women presenting themselves with this symp-tom should be subjected to a painstaking, gentle, but thoroughdiagnostic curettage. Endocervical curettage is an essentialpart of the operation. The search for cancer should be tho-roughly done. X-ray hysterography, at times, is of greatassistance, indicating to which region, possibly behind afibroid, or in pyometria, the curette should be directed.849850 S.A. MEDICAL JOURNAL 10 October 1959Good observation has brought to light that a large-framed,relatively infertile, hypertensive woman who gives a story ofa meno- and metrorrhagic climacteric period and a latemenopause, and who has diabetes, is likely to developendometrial cancer. It is of interest that of the 134 patientsadmitted to Groote Schuur Hospital during the period 1952-57, 27 had either frank diabetes or abnormal blood-sugarcurves. A further analysis of this finding will' be presentedshortly.Bleeding after the menopause may be found in associationwith large ovarian tumours-whether malignant or benign,functioning or non-functioning. Obviously the bleedingfound in association with functioning tumours is mainly dueto hyper-oestrogenism. The endometrium responds to thehormonal stimulus and with the flow and ebb of the circulatingoestrogen it either grows or sloughs. In all probability theuterine bleeding found in association with large genita!tumours is due to the various congestions mechanically pro-duced by these lumps.Sloughing and ulceration of a surface will result in bleeding.It is therefore also found in cancers of the vulva and vagina,whether primary or secondary.Sarcomata of the genitalia are uncommon and may be thecause of bleeding.As a general rule fibroids decrease in size after the involu-tionary change of the menopause. However, bleeding may becaused if the fibroid increases in bulk owing to a degenerativechange or if it becomes submucous and pedunculated. Erosionof the surface of the fibroid tumour may result in profusebleeding; in rare cases this occurs also with benign vaginal andvulvallesions.Oestrogen excess. As normal endometrial bleeding· isdependent upon hormonal influences, and as oestrogens areendometrial 'building' hormones, it does not require anystretch of imagination to realize that if oestrogens are adminis-tered for long periods, e.g. for controlling adverse menopausalphenomena, endometrial growth will result. Variation in theamount of circulating oestrogen will affect the endometrium,and may produce sloughing with concomitant bleeding. Thesame effects will be produced by tumours that produceoestrogen, e.g. granulosa-cell tumours or thecomata. In somewomen, for an inexplicable reason, a rejuvenescence of theovaries occurs postmenopausally. This will result in oestro-gen secretion, in turn followed by vaginal bleeding. Curettagewill reveal endometrium in the proliferative phase.Oestrogen deficiency, on the other hand, leads to vaginaland endometrial cellular atrophy. Haemorrhagic 'spotting'from these surfaces may therefore occur in the clinical con-ditions of senile vaginitis and senile endometritis. Of greatimportance, however, is the fact that with cellular atrophyinfection may readily supervene. Both acute and chronicinfection may produce a blood-stained vaginal discharge.Should the cervix be occluded, pus will collect in the uterus,which gradually distends and becomes a veritable bag of pus-pyometra-a condition "frequently associated with uterinecancer.Trauma. With the decrease in oestrogens following themenopause, the supports of the genitalia are adverselyaffected and symptoms and signs of a previous 'weakening' inthis region may become aggravated. A prolapse may pro-ceed apace and unless properly attended to will become com-plete. As the cervix is at the tip of the now inverted vagina,the area around it gradually becomes denuded of epitheliumbecause of constant trauma and a poor return of venousblood and lymph. The ulcer so formed remains indolentuntil treated by vaginal replacement, hormone administrationand cleanliness. An improperly fitting or rough-surfacedpessary will also erode away epithelium and be responsiblefor the production of an ulcer with bleeding. Vulval andvaginal injury by rape or by accident (falling on a hardobject) will obviously cause bleeding.Extra-genital bleeding. Tot infrequently women state thattheir underclothes are bloodstained but that they cannotlocate the origin of the bleeding;. it may come from theurethra, vagina or anus. Inspection may reveal a caruncle ora bleeding pile, or the history and physical findings will pointto urinary, anal or rectal pathology.CONCLUSIONVery briefly most of the major causes of post-menopausalbleeding have been discussed. It must always be borne inmind that, no matter whether, for example, senile vaginitisor a urinary caruncle is found, the onus of making sure thata hidden cancer does not exist in the genital tractfalls squarely on the shoulders of the medical attendant. Itcertainly will not benefit the patient if she is treated for senilevaginitis when, in addition, she has a cancer of the endo-metrium.No woman who suffers from post-menopausal bleedingshould be treated before cancer has been properly excluded.Any deviation from this principle will lead to untold andunnecessary suffering. The treatment for cancer is radical andpossibly even maiming. The longer the disease has beenmissed clinically, the poorer are the patient's chances ofsurvival. How sad it is to know that more mistakes in diag-nosis are made by not thinking than by not knowing! To-gether we must be on guard against this meqtal trap of slug-gish thought and deed.CONSIDERATIO TS ON THE AETIOLOGY OF URINARY CALCULI*.CYRIL WIGGISHOFF, M.A., B.M. (Oxo..), ER.C.S. (E 'G.), F.R.C.S. (£DIN.), Johannesburg-,In 1934 Mr. Swift loly,' Senior Surgeon to St. Peter's Hospitalfor Stone, London, whose book on Stone is a classic, remarkedin his Ramon Guitteras lecture to the American UrologicalAssociation that the incidence of urinary stones had greatlydiminished in the previous century. This had occurred principallyin countries where living standards had improved, and mainlyamongst children and young adults. In marshalling factors heconsidered to be of importance in the aetiology of urinary calculihe brought out the following points.* This paper was presented at the Surgical Club of the University of Illinois,Chicago, 12 June 1958. -CA) Geographical distribUliotl. Well demarcated areas existwhere stones are more commonly found. These areas differ fromone another geologically, climatically, and phylogenetically, andno common denominator to account for the higher incidence ofurinary calculi in the populations of these localities has beenfound.(B) Diet. Urinary stones are commoner where cereals are thestaple food, and this ties in to a certain extent with the geographicaldistribution of stones, but by no means explains it completely.For instance, Southern China, which is a stone area, has riceas its staple diet, yet this is generally considered to have a lower

Post menopausal bleeding

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Post menopausal bleeding

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