Objectives Summarize the key features of a patient presenting with postmenopausal bleeding, capturing the information essential for differentiating between the common and dont miss etiologies. Describe the initial management of menopausal symptoms. Describe an evidence-based plan for appropriate screening, assessment of risk, and counseling on wellness and risk reduction for women over 50. Conduct a focused history and physical exam appropriate for differentiating between common and “don’t miss” conditions for a patient presenting with postmenopausal bleeding. Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with atrophic vaginitis. Describe an evidence-based management plan that includes pharmacologic treatment, surveillance, and prevention of osteoporosis. Propose a cost-effective diagnostic work-up for a patient presenting with postmenopausal bleeding. Knowledge Definition of Menopause Menopause is a normal process that occurs as the ovaries are depleted of follicles and produce less estrogen. It is thought that the lack of estrogen leads to the majority of postmenopausal symptoms. In the U.S., menopause happens at a median age of 51.3 years, and between 40 and 58 years of age for most patients. The natural process leading up to menopause may take several years, and it can be difficult to make a firm diagnosis. National guidelines define menopause as having occurred when someone has not had a period for 12 months. Some physicians may also confirm menopause by ordering FSH and LH levels, which are both elevated in menopausal people. Symptoms of Menopause Occurring in up to 82 percent of menopausal patients, hot flashes or vasomotor symptoms are the most common symptoms of menopause. Many patients will also experience symptoms of atrophic vaginitis, which can lead to vaginal dryness and dyspareunia (pain during intercourse), and urinary symptoms. Since menopause can be associated with a variety of additional symptomsincluding sexual dysfunction, sleep disturbance, mood disturbance, and concentration difficultiesit can significantly affect a patient’s daily functioning and quality of life. Initial History for Vaginal Bleeding in Postmenopausal Patients Detailed description of recent bleeding (time course, amount, color) and associated symptoms (that could suggest infection, anemia, or malignancy) Last menstrual period Other gynecological problems, including previous pelvic surgeries or a history of abnormal Pap tests Personal history of coagulopathies or “bleeding too much” Family history of cancer or bleeding problems Detailed medication history, including as-needed medications and/or supplements and anticoagulants Review health maintenance, with special attention to the last Pap test Screening for Females in Their 50s Without Risk Factors Breast Cancer Screening There are conflicting recommendations for screening mammography: U.S. Preventive Service Task Force (USPSTF) Recommends biennial screening mammography for patients with breasts aged 4074. (They found insufficient evidence to assess the benefits and harms for those over age 75.) The USPSTF recognizes that patients with a first-degree relative with a history of breast cancer are at higher risk for breast cancer. 2026 Aquifer, Inc. – Maureen Francis (mfrancis050@usuniversity.edu) – 2026-03-30 20:25 PDT 1/9 The American Cancer Society (ACS) Recommends yearly screening mammograms starting at age 45. At age 55 a person can continue to have yearly mammograms or transition to biennial mammograms. For people between 40 and 44, the ACS recommends having an informed discussion of risks and benefits with the patient. Mammograms should continue until the patients life expectancy is less than 10 years. The American College of Obstetricians and Gynecologists (ACOG) Patients should be offered mammograms starting at age 40 annually or biennially. Mammograms for screening should be initiated no later than age 50. Continue mammograms through age 75, then make decisions with consideration for overall health and longevity. As shared decision-making is increasingly highlighted in guidelines, risk assessment tools can be helpful in individualizing recommendations. Colon cancer screening The USPSTF recommends colon cancer screening for average-risk patients, regardless of gender, to begin at age 45. This recommendation is a B grade evidence for ages 45-49 and an A grade for ages 50-75. The USPSTF recommends selectively offering colon cancer screening between ages 76 to 85, but the decision on whether to screen should be individualized based on the patients risk, prior screening results, and patient preferences. They recommend against (D grade) screening after the age of 85. The American Cancer Society recommendations for colon cancer screening mirror those of the USPSTF. Pap test Regular screening with Pap tests (cytology) has been very effective at reducing mortality from cervical cancer in screened populations. Extensive research and newer technologies have allowed for more precise guidelines for cervical cancer screening in patients of average risk. Recommendations from the American Society for Colposcopy and Cervical Pathology and the USPSTF call for Pap test screening to start at age 21 and continue every three years until age 30. Preferred screening from age 30 to 65 is HPV testing in addition to the cytology test (Pap) every five years or high-risk HPV testing alone every five years. The availability of HPV testing as the primary test may depend on the institution. A history of specific gynecologic pathology or certain risk factorssuch as HIV, immunosuppression, DES exposure (while in utero), or history of cervical cancermay support more frequent Pap tests. These guidelines do not currently recommend against testing more often if the clinician feels it is indicated, or if the patient requests more frequent screening. Pap tests are not indicated for patients who have had a hysterectomy with complete removal of the cervix for noncancer reasons, and also do not have a history of CIN2 or greater lesions. Physical Examination for Abnormal Uterine Bleeding Pelvic exam: Look for vulvar or vaginal lesions, signs of trauma, and cervical polyps or other lesions. Assess the amount of bleeding, and look for any vaginal discharge; which could be a sign of infection. On bimanual examination, assess the size and mobility of the uterus; as a firm, a fixed uterus would be concerning for uterine cancer. Neck exam: Thyroid exam to look for goiter or nodules, as thyroid disease is one of several systemic diseases that can cause dysfunctional uterine bleeding. Skin exam: Look for evidence of bleeding disorders, like bruises. Also, jaundice on the skin exam and hepatomegaly on an abdominal exam might signify an underlying acquired coagulopathy from liver disease. Symptoms and Findings of Atrophic Vaginitis Symptoms: Vaginal dryness, dyspareunia, urinary symptoms, and vaginal pruritis. Urinary symptoms: Recurrent urinary tract infections, urinary frequency and urgency, and dysuria. Local estrogen may help patients with urge incontinence and recurrent urinary tract infections. We’re not sure if estrogen helps with overactive bladder, and there is conflicting evidence about its effect on stress incontinence. Vaginal pruritis: Local symptoms are usually best treated with topical estrogen in the form of either a vaginal cream or an estrogen ring, which is an estrogen-impregnated ring inserted into the vagina. Physical exam findings: Smoother vaginal mucosa and cervix, related to postmenopausal changes from decreased estrogen levels. Risk Factors for Endometrial Cancer The following increase levels of unopposed estrogen and thereby increase the risk for endometrial cancer: Estrogen therapy without progesterone Tamoxifen (Nolvadex)Often used in patients with breast cancer or who are at high risk for breast cancer and has an estrogenic effect on the genital tract. Obesity Anovulatory cycles Estrogen-secreting neoplasms Early menarche (before a Late menopause (after age 52) 2026 Aquifer, Inc 20:25 PDT 2/9 Menstrual cycle irregularities Nulliparity Conversely, smoking seems to decrease estrogen exposure, thereby decreasing the cancer risk, and oral contraceptive use increases progestin levels, thus providing protection. Other risk factors for endometrial cancer include hypertension, diabetes, hypothyroidism, and breast or colon cancer. Age is also a risk factor for endometrial cancer. The incidence of endometrial cancer more than doubles from 2.8 cases per 100,000 in those ages 30 to 34 years to 6.1 cases per 100,000 in those ages 35 to 39 years. Thus, the American College of Obstetricians and Gynecologists recommends endometrial evaluation in patients ages 35 years and older who have abnormal uterine bleeding. When to Screen for Osteoporosis The United States Preventive Services Task Force recommends osteoporosis screening for all females over the age of 65 and for younger patients who have an increased risk of a major osteoporotic fracture (MOF). The FRAX score is a commonly used tool to assess risk. A ten-year risk of MOF above ~9% may be used to indicate increased risk of osteoporosis and a need for early screening. While the USPSTF found insufficient evidence to recommend screening in men, the FRAX includes calculations for men and may provide useful information about their fracture risk. Osteoporosis Risk Factors Corticosteroid use Family history of osteoporosis, especially if a first-degree relative has fractured a hip Previous fragility fracture is defined as a low-impact fracture Smoking Heavy alcohol use Lower body weight (weight < 70 kg) is the single best predictor of low bone mineral density In epidemiological studies, Black patients demonstrate higher bone density than White patients at all ages. White race, therefore, is frequently cited as a risk factor for osteoporosis, and the FRAX tool includes a patients race in its calculations. Students should remember that there is no viable biological definition of race. The observed variations in bone density may be explained by social determinants of health, and a patients family history (i.e., heredity) is a more important risk factor than race. Furthermore, there are clear racial disparities in screening, diagnosis, and treatment of osteoporosis that negatively affect African American patients. Strategies to Prevent Osteoporosis Smoking cessation. Smoking increases the risk of osteoporosis. Adequate intake of calcium and vitamin D are essential to normal human physiology including bone health. A number of organizations have recommended routine supplementation of these nutrients for a variety of reasons including the prevention of osteoporosis. However, this recommendation is now being questioned. The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of daily supplementation with > 400 IU of vitamin D3 and 1,000 mg of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal patients. It recommends against daily supplementation with lower doses for the primary prevention of fractures because there is no demonstrated benefit at this dose and supplementation increases the risk of nephrolithiasis. The USPSTF does not address the daily dietary requirements of these nutrients, only the use of these supplements to prevent osteoporosis and certain cancers. It does illuminate the risk of the widespread calcium and vitamin D supplementation and the relative lack of good research demonstrating benefits for osteoporosis. Pending further evidence, it is reasonable to encourage otherwise healthy patients at risk for osteoporosis to consume adequate amounts of calcium and vitamin D. Typical doses would include 1,200 mg of calcium and 800 to 1,000 IU of vitamin D daily. People of this age typically only consume about 600 to 700 mg of calcium and 156 IU of vitamin D daily. Increasing dietary intake of these nutrients should be the first-line approach, but supplements may be needed when adequate dietary intake cannot be achieved and when Vitamin D deficiency is demonstrated. Vitamin D plays a major role in calcium absorption, bone health, muscle performance, balance, and risk of falling. Chief dietary sources of vitamin D include fortified milk and cereals, egg yolks, saltwater fish, and liver. Overuse of calcium and vitamin D can be harmful and patients should be advised against taking high doses of these supplements, especially without a thoughtful review of their diet and medical history. Unfortunately, patients may get conflicting information. Approximately 5% of women over 50 exceed the recommended upper intake level of 2,500 mg per day for calcium. The upper intake level for vitamin D in healthy adults is currently listed as 4,000 IU per day. There is significant emerging research and recommendations regarding these nutrients but clear guidelines are still pending. Lifelong weight-bearing exercise (bones and muscles work against gravity as the feet and legs bear the body’s weight) and muscle strengthening can improve agility, strength, posture, and balance, which may reduce the risk of falls. It may also modestly increase bone density. Examples of weight-bearing exercises include walking, jogging, Tai Chi, stair climbing, dancing, and tennis. Osteoporosis: Consequences, Fall Prevention, and Diagnosis Consequences 2026 Aquifer, Inc. – Maureen Francis (mfrancis050@usuniversity.edu) – 2026-03-30 20:25 PDT 3/9 Patients with osteoporosis can suffer a fracture following even minimal trauma. These fractures are most commonly of the vertebrae, the hip, distal radius, and proximal humerus. The lifetime risk of fracture for a 50-year-old female exceeds her risk of developing endometrial or breast cancer. Fractures secondary to osteoporosis place enormous personal, medical, and economic burdens on the elderly. Patients with hip fractures have an average one-year mortality rate of 2025%. Hip fractures are associated with significant loss of independence, with 1525% of previously independent patients requiring nursing home placement for at least one year, and less than 30% of patients regaining their pre-fracture level of function. Fall Prevention Strategies to reduce falls include checking and correcting vision and hearing, evaluating any neurological problems, reviewing prescription medications for side effects affecting balance, and providing a checklist for improving safety at home. Diagnosis A DEXA scan is a bone densitometry study that usually looks at the lumbar spine and hip density to determine if someone has osteoporosis. This is done based on a T-score. A T-score of -1.0 to -2.5 is consistent with decreased bone density or osteopenia. Osteopenia is not a clinical diagnosis and just indicates the degree of bone decline since peak bone mass. It is usually not an indication for treatment aside from lifestyle modifications. A T-score of less than -2.5 indicates osteoporosis. Based on the patient’s risk for fracture and their T-score, we can then make recommendations for the treatment of osteoporosis. The T-score is a statistical measure that compares one person’s bone mass density (BMD) in standard deviations to the average peak bone mass density in a young healthy person. A zero value is the average BMD for a young healthy person and the T-score is then the number of standard deviations from that mean. For instance, a T-score of -1.0 indicates a bone density that is one standard deviation below the BMD of a young healthy person. This statistic is then used to classify the BMD of an individual into normal (0 to -1), osteopenia (-1 to -2.5), and osteoporosis (below -2.5). Clinical Skills How to Perform a Pelvic Exam In preparation for the pelvic exam, ensure you have all the required equipment: light source, speculum, thin prep and brush, and lubricant. Assess whether the patient has any questions or concerns about the exam, and ensure you adequately address them before beginning. Then, elevate the head of the exam table to 30 to 45 degrees. Have the patient slide down on the exam table and help her position her feet in the footrests. Cover her legs with a sheet and ask her to allow her knees to fall laterally just beyond the angle of the footrests. Then, let the patient know you are about to begin the speculum exam. Once she has acknowledged this, insert a warm, lubricated speculum into the vagina to visualize the vaginal walls and cervix. Obtain a Pap test (if indicated) and slowly remove the speculum. Then perform a bimanual exam (if indicated). How to Perform An Endometrial Biopsy Prior to the procedure, verify that the patient understands the procedure and the risks of (1) bleeding or (2) uterine perforation (which is rare), and signs a consent form. First, help the patient get into the lithotomy position. Insert a speculum and visualize the cervix. Apply betadine solution to the cervix. Apply topical lidocaine to the cervix or perform a paracervical block for pain control. Then, use a tenaculum (forceps with a sharp hook at the end of each jaw used for grasping tissues in surgery) to grasp the cervix on the superior/anterior portion. Apply anterior traction. Next, insert the pipelle into the os and obtain specimens from at least four different areas of the uterus. Withdraw the pipelle and place the samples into the formalin. Remove the tenaculum and speculum. The specimen is sent in formalin to the lab. Management Benefits and Risks of Menopausal Hormone Therapy Benefits of menopausal hormone therapy The primary function of menopausal hormone therapy (HT) is to treat the bothersome symptoms of menopause. Systemic estrogen is the most effective treatment for hot flashes or vasomotor symptoms. Patients with an intact uterus must also be treated with progesterone to decrease the risk of endometrial cancer related to unopposed estrogen. Estrogen, especially when used topically, is also the most effective treatment for symptoms of atrophic vaginitis, including vaginal dryness and dyspareunia, and may improve urinary symptoms such as urge incontinence and recurrent urinary tract infections. Topical estrogens (available as an insert, cream, or ring) are safe in low doses and, in these doses, probably do not require coverage with progesterone even in patients with an intact uterus. Menopausal HT, especially when started in the first five years after menopause, helps prevent osteoporosis by maintaining bone density. For many years, HT was used extensively for this purpose. While osteoporosis prevention may be a benefit of HT used to treat menopausal 2026 Aquifer, Inc. – it is not recommended as an agent for the sole purpose of osteoporosis or other chronic disease prevention. The USPSTF gives HT a “D” rating for the average risk patient for chronic disease prevention, as the harms outweigh the potential benefits. It is still considered an option when the risk-to-benefit ratio favors HT over other treatments. Research results on the use of HT for other menopause-related quality-of-life issues, including cognitive and depressive symptoms, present less clear outcomes. Risks of menopausal hormone therapy While the particular risks for groups of patients are still being defined, recent reviews of the available evidence have provided some key practice recommendations, including: 1. Combined estrogen and progestogen use beyond three years increases the risk of breast cancer. 2. The use of unopposed systemic estrogen in patients with a uterus increases endometrial cancer risk. 3. Beginning HT after age 60 increases the risk of coronary artery disease. 4. HT increases the risk of stroke at least for the first one to two years of use. 5. HT for menopausal symptoms should use the lowest effective doses for the shortest possible time. HT includes the use of estrogen alone or the use of estrogen combined with progesterone. It can improve health-related quality of life by improving vasomotor and atrophic vaginitis symptoms caused by menopause. Routine use of HT decreased when research, including the Women’s Health Initiative (WHI), revealed greater than expected risks associated with HT for the subjects in their study. However, it remains an acceptable consideration in younger patients before the age of 60 with few risk factors. Impact of HT on Chronic Disease Outcomes Combined estrogen/progesterone Estrogen alone Harms per 10,000 person-yearsHarms per 10,000 person-years Breast cancer 51 CAD 31 Dementia 88 Dementia 63 Gallbladder disease 260 Gallbladder disease377 Stroke 52 Stroke 79 DVT 120 DVT 77 Incontinence 562 Incontinence 885 Benefits per 10,000 person-yearsBenefits per 10,000 person-years Diabetes-78 Diabetes-134 Fractures-230 Fractures-388 Breast cancer-52 Colorectal cancer-34 Table adapted from: Gartlehner G, Patel SV, Reddy S, Rains C, Schwimmer M, Kahwati L. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022;328(17):1747-1765. How to Decide When to Use Hormone Therapy Hormone therapy can be a helpful treatment for the symptoms of hot flashes and it will help delay bone loss, but it can increase the risk of breast cancer, heart attack, stroke, DVT, and incontinence. Whether or not to use HT can be a difficult decision and therefore must be individualized for each patient. There is no right answer for all patients. Our role as providers is to use the best evidence we have to help patients identify their own unique risks for adverse effects from HT. Then, we can help the patient weigh the potential benefits against her personal risks. Risk factors to consider include: 2026 Aquifer, Inc. – Maureen Francis (mfrancis050@usuniversity.edu) – 2026-03-30 20:25 PDT 5/9 Age Family and personal history of heart disease, stroke, breast cancer, blood clots, or osteoporosis Medications Quality of life plays a large role in this decision. How bothersome are the menopausal symptoms? What are the patient’s preferences regarding prescription medication versus herbal supplements or other strategies? What are their fears? Shared decision-making: In these situations where there is no right answer, the role of the clinician is more of a counselor and to provide information. The responsibility of decision-making shifts to the patient, as only they can balance their quality of life against the risks they are willing to accept. In general, HT for menopausal symptoms should use the lowest effective doses for the shortest possible time, which means we should regularly discuss the risks and benefits of continuing the therapy with patients. Osteoporosis Treatment Bisphosphonates are potent inhibitors of bone resorption and reduce bone turnover, resulting in increased bone mineral density. Bisphosphonates have been shown to decrease the risk of vertebral and nonvertebral fractures. Alendronate (Fosamax) and risedronate (Actonel) are available in generic form, making them more affordable. These can be given daily, monthly orally, or by IV. The total duration of treatment should be 5 years for the oral or 3 years for the IV. Ibandronate (Boniva) is only available by trade name and the cost may be prohibitive to some patients. Zoledronic acid, an intravenous preparation, is given annually and can be used in patients who do not tolerate oral bisphosphonates. Teriparatide (Forteo) is a parathyroid hormone analog and is approved by the FDA for those with osteoporosis at high risk for fracture. It is given subcutaneously and has been shown to decrease fracture risk by 50% to 65%. It does not have demonstrated efficacy and safety beyond two years and is quite costly. Raloxifene is a selective estrogen receptor modulator (SERM) that is used if bisphosphonates are not tolerated but has only been shown to have efficacy in preventing vertebral fractures. Calcitonin binds to osteoclasts, thereby inhibiting bone reabsorption. It has been shown to reduce vertebral fractures, but not hip or other fractures. For most patients, more effective treatments are available. Denosumab is an alternate second-line therapy for patients at high risk of osteoporotic fracture. It inhibits osteoclast formation and survival thereby reducing bone resorption. It is administered in an IV infusion every 6 months and is very costly. Management of Hot Flashes Hormone therapy still has a role in the treatment of hot flashes and other menopausal symptoms in patients at low risk for hormone-related diseases but should be used at the minimum effective dose for the least amount of time, generally 3-5 years although some women will have hot flashes once the HT is stopped. Other prescription medications, including the antidepressants SSRIs and SNRIs, and clonidine and gabapentin, although less effective than HT for vasomotor symptoms, can be beneficial in selected patients. Additionally, fezolinetant was approved by the FDA in 2023 for the treatment of hot flashes and may be an option for some patients. The National Center for Complementary and Integrative Health identified some weak evidence to support the use of hypnotherapy and mindfulness for the management of menopausal symptoms, but outlines specific concerns and recommends against the use of compounded hormones marketed as bioidentical hormone replacement therapy and against the use of DHEA. Furthermore, natural medicines, such as phytoestrogens and botanicals, have not been shown to be clearly safe and effective according to usual standards for prescription medications. Information from The National Center for Complementary and Integrative Health (NCCIH) publication Menopausal Symptoms and Complementary Health Practices: Yoga, tai chi, qi gong, and acupuncture: There is inconsistent evidence to support their effectiveness. Phytoestrogens are found in certain plants such as soy and red clover: There is inconsistent evidence to support their use and they may be harmful in certain patients, particularly those with cancer. Products made from these plants can act like estrogen in the body, but more research needs to be done before they can be widely recommended for the treatment of menopausal symptoms. They may not be safe for patients at risk for hormonally related diseases. Botanicals such as black cohosh: Black cohosh (Actaea racemosa, Cimicifuga racemosa): A 2012 Cochrane review found no benefit from the use of black cohosh for treating hot flashes. Bioidentical hormone replacement therapy and DHEA: Bioidentical hormone replacement therapy is a marketing term for hormone-containing medicines prepared in special pharmacies. Their content isn’t regulated in the way that prescription medications are, and they have not been tested or approved by the FDA. Their safety cannot be assumed and they lack clear prescribing guidelines. DHEA is sold as a dietary supplement and is metabolized into estrogen and testosterone in the body. It has not been proven to be safe or effective and may increase the risk of hormone-related diseases. 2026 Aquifer, Inc. – Maureen Francis (mfrancis050@usuniversity.edu) – 2026-03-30 20:25 PDT 6/9 Studies Evaluation of Postmenopausal Bleeding Transvaginal ultrasound (TVUS) TVUS may be the most cost-effective initial test in patients at low risk for endometrial cancer who have abnormal uterine bleeding. The TVUS will tell us the thickness of the endometrium. If the endometrium is less than 4 mm (some sources say < 5 mm) on ultrasound, it is reassuring and more workup may not be necessary unless the bleeding continues. Besides endometrial thickening, TVUS may reveal leiomyoma (fibroids) or focal uterine masses, as well as ovarian pathology. Endometrial biopsy Office-based sampling using the Pipelle device has a sensitivity for detecting endometrial cancer in postmenopausal women as high as 99%. An endometrial biopsy will obtain a tissue sample that is sent to Pathology to look for evidence of endometrial hyperplasia or endometrial cancer. Complete blood count A complete blood count might be helpful to demonstrate the absence of anemia and thrombocytopenia. An abnormal result would trigger further systemic evaluation. Thyroid-stimulating hormone level Thyroid disorders may cause abnormal uterine bleeding and are associated with an increased risk for endometrial cancer. We assess thyroid function via an inexpensive blood test for thyroid-stimulating hormone (TSH). Clinical Reasoning Differential of Abnormal Uterine Bleeding Most Important/Most Likely Diagnoses Cervical polyps Most common in postpartum and perimenopausal patients; rare in premenstrual and postmenopausal patients. Although cervical polyps are rare in postmenopausal patients, they can occur and may present with vaginal bleeding. Endometrial hyperplasia With or without atypia can cause bleeding. Simple hyperplasia progresses to cancer in less than 5% of patients; atypical complex hyperplasia is a premalignant lesion that has a 25% probability of progressing to cancer. Therefore, careful monitoring and treatment is important with this disorder. Hormone producing ovarian tumors Rare Most ovarian cancers do not cause postmenopausal bleeding or other significant symptoms, but postmenopausal bleeding is one of several symptoms associated with a higher risk for ovarian cancer (6.6-fold increased risk). Other possible symptoms of ovarian cancer include pelvic or abdominal pain, an increase in abdominal size or bloating, and early satiety. Endometrial cancer The fourth most common cancer in patients with uteri , and the main “can’t miss” diagnosis that must be considered in patients presenting with postmenopausal bleeding. Must be considered in patients over the age of 35 with symptoms suggestive of anovulatory bleeding (spotting, menorrhagia, metrorrhagia). Ninety percent of patients with endometrial cancer have abnormal vaginal bleeding. Proliferative endometrium Normal response to estrogen stimulation in premenopausal patients. Occasionally, postmenopausal patients, particularly those in higher estrogen states, can produce a similar endometrial response. On biopsy, this condition may be hard to differentiate from simple hyperplasia. Other possible causes of abnormal uterine bleeding Other possible causes of abnormal uterine bleeding across the age spectrum are medications (including anticoagulants, selective serotonin reuptake inhibitors, antipsychotics, corticosteroids, and hormonal medications) and disorders involving the thyroid, hematologic, hepatic, adrenal, pituitary, and hypothalamic systems. Cervical cancer may also present with vaginal bleeding, although light spotting would be most common.ning Objectives Summarize the key features of a patient presenting with postmenopausal bleeding, capturing the information essential for differentiating between the common and dont miss etiologies. Describe the initial management of menopausal symptoms. Describe an evidence-based plan for appropriate screening, assessment of risk, and counseling on wellness and risk reduction for women over 50. Conduct a focused history and physical exam appropriate for differentiating between common and “don’t miss” conditions for a patient presenting with postmenopausal bleeding. Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting with atrophic vaginitis. Describe an evidence-based management plan that includes pharmacologic treatment, surveillance, and prevention of osteoporosis. Propose a cost-effective diagnostic work-up for a patient presenting with postmenopausal bleeding. Knowledge Definition of Menopause Menopause is a normal process that occurs as the ovaries are depleted of follicles and produce less estrogen. It is thought that the lack of estrogen leads to the majority of postmenopausal symptoms. In the U.S., menopause happens at a median age of 51.3 years, and between 40 and 58 years of age for most patients. The natural process leading up to menopause may take several years, and it can be difficult to make a firm diagnosis. National guidelines define menopause as having occurred when someone has not had a period for 12 months. Some physicians may also confirm menopause by ordering FSH and LH levels, which are both elevated in menopausal people. Symptoms of Menopause Occurring in up to 82 percent of menopausal patients, hot flashes or vasomotor symptoms are the most common symptoms of menopause. Many patients will also experience symptoms of atrophic vaginitis, which can lead to vaginal dryness and dyspareunia (pain during intercourse), and urinary symptoms. Since menopause can be associated with a variety of additional symptomsincluding sexual dysfunction, sleep disturbance, mood disturbance, and concentration difficultiesit can significantly affect a patient’s daily functioning and quality of life. Initial History for Vaginal Bleeding in Postmenopausal Patients Detailed description of recent bleeding (time course, amount, color) and associated symptoms (that could suggest infection, anemia, or malignancy) Last menstrual period Other gynecological problems, including previous pelvic surgeries or a history of abnormal Pap tests Personal history of coagulopathies or “bleeding too much” Family history of cancer or bleeding problems Detailed medication history, including as-needed medications and/or supplements and anticoagulants Review health maintenance, with special attention to the last Pap test Screening for Females in Their 50s Without Risk Factors Breast Cancer Screening There are conflicting recommendations for screening mammography: U.S. Preventive Service Task Force (USPSTF) Recommends biennial screening mammography for patients with breasts aged 4074. (They found insufficient evidence to assess the benefits and harms for those over age 75.) The USPSTF recognizes that patients with a first-degree relative with a history of breast cancer are at higher risk for breast cancer. 2026 Aquifer, Inc. – 2026-03-30 20:25 PDT 1/9 The American Cancer Society (ACS) Recommends yearly screening mammograms starting at age 45. At age 55 a person can continue to have yearly mammograms or transition to biennial mammograms. For people between 40 and 44, the ACS recommends having an informed discussion of risks and benefits with the patient. Mammograms should continue until the patients life expectancy is less than 10 years. The American College of Obstetricians and Gynecologists (ACOG) Patients should be offered mammograms starting at age 40 annually or biennially. Mammograms for screening should be initiated no later than age 50. Continue mammograms through age 75, then make decisions with consideration for overall health and longevity. As shared decision-making is increasingly highlighted in guidelines, risk assessment tools can be helpful in individualizing recommendations. Colon cancer screening The USPSTF recommends colon cancer screening for average-risk patients, regardless of gender, to begin at age 45. This recommendation is a B grade evidence for ages 45-49 and an A grade for ages 50-75. The USPSTF recommends selectively offering colon cancer screening between ages 76 to 85, but the decision on whether to screen should be individualized based on the patients risk, prior screening results, and patient preferences. They recommend against (D grade) screening after the age of 85. The American Cancer Society recommendations for colon cancer screening mirror those of the USPSTF. Pap test Regular screening with Pap tests (cytology) has been very effective at reducing mortality from cervical cancer in screened populations. Extensive research and newer technologies have allowed for more precise guidelines for cervical cancer screening in patients of average risk. Recommendations from the American Society for Colposcopy and Cervical Pathology and the USPSTF call for Pap test screening to start at age 21 and continue every three years until age 30. Preferred screening from age 30 to 65 is HPV testing in addition to the cytology test (Pap) every five years or high-risk HPV testing alone every five years. The availability of HPV testing as the primary test may depend on the institution. A history of specific gynecologic pathology or certain risk factorssuch as HIV, immunosuppression, DES exposure (while in utero), or history of cervical cancermay support more frequent Pap tests. These guidelines do not currently recommend against testing more often if the clinician feels it is indicated, or if the patient requests more frequent screening. Pap tests are not indicated for patients who have had a hysterectomy with complete removal of the cervix for noncancer reasons, and also do not have a history of CIN2 or greater lesions. Physical Examination for Abnormal Uterine Bleeding Pelvic exam: Look for vulvar or vaginal lesions, signs of trauma, and cervical polyps or other lesions. Assess the amount of bleeding, and look for any vaginal discharge; which could be a sign of infection. On bimanual examination, assess the size and mobility of the uterus; as a firm, a fixed uterus would be concerning for uterine cancer. Neck exam: Thyroid exam to look for goiter or nodules, as thyroid disease is one of several systemic diseases that can cause dysfunctional uterine bleeding. Skin exam: Look for evidence of bleeding disorders, like bruises. Also, jaundice on the skin exam and hepatomegaly on an abdominal exam might signify an underlying acquired coagulopathy from liver disease. Symptoms and Findings of Atrophic Vaginitis Symptoms: Vaginal dryness, dyspareunia, urinary symptoms, and vaginal pruritis. Urinary symptoms: Recurrent urinary tract infections, urinary frequency and urgency, and dysuria. Local estrogen may help patients with urge incontinence and recurrent urinary tract infections. We’re not sure if estrogen helps with overactive bladder, and there is conflicting evidence about its effect on stress incontinence. Vaginal pruritis: Local symptoms are usually best treated with topical estrogen in the form of either a vaginal cream or an estrogen ring, which is an estrogen-impregnated ring inserted into the vagina. Physical exam findings: Smoother vaginal mucosa and cervix, related to postmenopausal changes from decreased estrogen levels. Risk Factors for Endometrial Cancer The following increase levels of unopposed estrogen and thereby increase the risk for endometrial cancer: Estrogen therapy without progesterone Tamoxifen (Nolvadex)Often used in patients with breast cancer or who are at high risk for breast cancer and has an estrogenic effect on the genital tract. Obesity Anovulatory cycles Estrogen-secreting neoplasms Early menarche (before age 12) Late menopause (after age 52) 2026 Aquifer, Inc. – Maureen Francis (mfrancis050@usuniversity.edu) – 2026-03-30 20:25 PDT 2/9 Menstrual cycle irregularities Nulliparity Conversely, smoking seems to decrease estrogen exposure, thereby decreasing the cancer risk, and oral contraceptive use increases progestin levels, thus providing protection. Other risk factors for endometrial cancer include hypertension, diabetes, hypothyroidism, and breast or colon cancer. Age is also a risk factor for endometrial cancer. The incidence of endometrial cancer more than doubles from 2.8 cases per 100,000 in those ages 30 to 34 years to 6.1 cases per 100,000 in those ages 35 to 39 years. Thus, the American College of Obstetricians and Gynecologists recommends endometrial evaluation in patients ages 35 years and older who have abnormal uterine bleeding. When to Screen for Osteoporosis The United States Preventive Services Task Force recommends osteoporosis screening for all females over the age of 65 and for younger patients who have an increased risk of a major osteoporotic fracture (MOF). The FRAX score is a commonly used tool to assess risk. A ten-year risk of MOF above ~9% may be used to indicate increased risk of osteoporosis and a need for early screening. While the USPSTF found insufficient evidence to recommend screening in men, the FRAX includes calculations for men and may provide useful information about their fracture risk. Osteoporosis Risk Factors Corticosteroid use Family history of osteoporosis, especially if a first-degree relative has fractured a hip Previous fragility fracture is defined as a low-impact fracture Smoking Heavy alcohol use Lower body weight (weight < 70 kg) is the single best predictor of low bone mineral density In epidemiological studies, Black patients demonstrate higher bone density than White patients at all ages. White race, therefore, is frequently cited as a risk factor for osteoporosis, and the FRAX tool includes a patients race in its calculations. Students should remember that there is no viable biological definition of race. The observed variations in bone density may be explained by social determinants of health, and a patients family history (i.e., heredity) is a more important risk factor than race. Furthermore, there are clear racial disparities in screening, diagnosis, and treatment of osteoporosis that negatively affect African American patients. Strategies to Prevent Osteoporosis Smoking cessation. Smoking increases the risk of osteoporosis. Adequate intake of calcium and vitamin D are essential to normal human physiology including bone health. A number of organizations have recommended routine supplementation of these nutrients for a variety of reasons including the prevention of osteoporosis. However, this recommendation is now being questioned. The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of daily supplementation with > 400 IU of vitamin D3 and 1,000 mg of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal patients. It recommends against daily supplementation with lower doses for the primary prevention of fractures because there is no demonstrated benefit at this dose and supplementation increases the risk of nephrolithiasis. The USPSTF does not address the daily dietary requirements of these nutrients, only the use of these supplements to prevent osteoporosis and certain cancers. It does illuminate the risk of the widespread calcium and vitamin D supplementation and the relative lack of good research demonstrating benefits for osteoporosis. Pending further evidence, it is reasonable to encourage otherwise healthy patients at risk for osteoporosis to consume adequate amounts of calcium and vitamin D. Typical doses would include 1,200 mg of calcium and 800 to 1,000 IU of vitamin D daily. People of this age typically only consume about 600 to 700 mg of calcium and 156 IU of vitamin D daily. Increasing dietary intake of these nutrients should be the first-line approach, but supplements may be needed when adequate dietary intake cannot be achieved and when Vitamin D deficiency is demonstrated. Vitamin D plays a major role in calcium absorption, bone health, muscle performance, balance, and risk of falling. Chief dietary sources of vitamin D include fortified milk and cereals, egg yolks, saltwater fish, and liver. Overuse of calcium and vitamin D can be harmful and patients should be advised against taking high doses of these supplements, especially without a thoughtful review of their diet and medical history. Unfortunately, patients may get conflicting information. Approximately 5% of women over 50 exceed the recommended upper intake level of 2,500 mg per day for calcium. The upper intake level for vitamin D in healthy adults is currently listed as 4,000 IU per day. There is significant emerging research and recommendations regarding these nutrients but clear guidelines are still pending. Lifelong weight-bearing exercise (bones and muscles work against gravity as the feet and legs bear the body’s weight) and muscle strengthening can improve agility, strength, posture, and balance, which may reduce the risk of falls. It may also modestly increase bone density. Examples of weight-bearing exercises include walking, jogging, Tai Chi, stair climbing, dancing, and tennis. Osteoporosis: Consequences, Fall Prevention, and Diagnosis Consequences 2026 Aquifer, Inc. – Maureen Francis (mfrancis050@usuniversity.edu) – 2026-03-30 20:25 PDT 3/9 Patients with osteoporosis can suffer a fracture following even minimal trauma. These fractures are most commonly of the vertebrae, the hip, distal radius, and proximal humerus. The lifetime risk of fracture for a 50-year-old female exceeds her risk of developing endometrial or breast cancer. Fractures secondary to osteoporosis place enormous personal, medical, and economic burdens on the elderly. Patients with hip fractures have an average one-year mortality rate of 2025%. Hip fractures are associated with significant loss of independence, with 1525% of previously independent patients requiring nursing home placement for at least one year, and less than 30% of patients regaining their pre-fracture level of function. Fall Prevention Strategies to reduce falls include checking and correcting vision and hearing, evaluating any neurological problems, reviewing prescription medications for side effects affecting balance, and providing a checklist for improving safety at home. Diagnosis A DEXA scan is a bone densitometry study that usually looks at the lumbar spine and hip density to determine if someone has osteoporosis. This is done based on a T-score. A T-score of -1.0 to -2.5 is consistent with decreased bone density or osteopenia. Osteopenia is not a clinical diagnosis and just indicates the degree of bone decline since peak bone mass. It is usually not an indication for treatment aside from lifestyle modifications. A T-score of less than -2.5 indicates osteoporosis. Based on the patient’s risk for fracture and their T-score, we can then make recommendations for the treatment of osteoporosis. The T-score is a statistical measure that compares one person’s bone mass density (BMD) in standard deviations to the average peak bone mass density in a young healthy person. A zero value is the average BMD for a young healthy person and the T-score is then the number of standard deviations from that mean. For instance, a T-score of -1.0 indicates a bone density that is one standard deviation below the BMD of a young healthy person. This statistic is then used to classify the BMD of an individual into normal (0 to -1), osteopenia (-1 to -2.5), and osteoporosis (below -2.5). Clinical Skills How to Perform a Pelvic Exam In preparation for the pelvic exam, ensure you have all the required equipment: light source, speculum, thin prep and brush, and lubricant. Assess whether the patient has any questions or concerns about the exam, and ensure you adequately address them before beginning. Then, elevate the head of the exam table to 30 to 45 degrees. Have the patient slide down on the exam table and help her position her feet in the footrests. Cover her legs with a sheet and ask her to allow her knees to fall laterally just beyond the angle of the footrests. Then, let the patient know you are about to begin the speculum exam. Once she has acknowledged this, insert a warm, lubricated speculum into the vagina to visualize the vaginal walls and cervix. Obtain a Pap test (if indicated) and slowly remove the speculum. Then perform a bimanual exam (if indicated). How to Perform An Endometrial Biopsy Prior to the procedure, verify that the patient understands the procedure and the risks of (1) bleeding or (2) uterine perforation (which is rare), and signs a consent form. First, help the patient get into the lithotomy position. Insert a speculum and visualize the cervix. Apply betadine solution to the cervix. Apply topical lidocaine to the cervix or perform a paracervical block for pain control. Then, use a tenaculum (forceps with a sharp hook at the end of each jaw used for grasping tissues in surgery) to grasp the cervix on the superior/anterior portion. Apply anterior traction. Next, insert the pipelle into the os and obtain specimens from at least four different areas of the uterus. Withdraw the pipelle and place the samples into the formalin. Remove the tenaculum and speculum. The specimen is sent in formalin to the lab. Management Benefits and Risks of Menopausal Hormone Therapy Benefits of menopausal hormone therapy The primary function of menopausal hormone therapy (HT) is to treat the bothersome symptoms of menopause. Systemic estrogen is the most effective treatment for hot flashes or vasomotor symptoms. Patients with an intact uterus must also be treated with progesterone to decrease the risk of endometrial cancer related to unopposed estrogen. Estrogen, especially when used topically, is also the most effective treatment for symptoms of atrophic vaginitis, including vaginal dryness and dyspareunia, and may improve urinary symptoms such as urge incontinence and recurrent urinary tract infections. Topical estrogens (available as an insert, cream, or ring) are safe in low doses and, in these doses, probably do not require coverage with progesterone even in patients with an intact uterus. Menopausal HT, especially when started in the first five years after menopause, helps prevent osteoporosis by maintaining bone density. For many years, HT was used extensively for this purpose. While osteoporosis prevention may be a benefit of HT used to treat menopausal 2026 Aquifer, Inc. – Maureen Francis (mfrancis050@usuniversity.edu) – 2026-03-30 20:25 PDT 4/9 symptoms, it is not recommended as an agent for the sole purpose of osteoporosis or other chronic disease prevention. The USPSTF gives HT a “D” rating for the average risk patient for chronic disease prevention, as the harms outweigh the potential benefits. It is still considered an option when the risk-to-benefit ratio favors HT over other treatments. Research results on the use of HT for other menopause-related quality-of-life issues, including cognitive and depressive symptoms, present less clear outcomes. Risks of menopausal hormone therapy While the particular risks for groups of patients are still being defined, recent reviews of the available evidence have provided some key practice recommendations, including: 1. Combined estrogen and progestogen use beyond three years increases the risk of breast cancer. 2. The use of unopposed systemic estrogen in patients with a uterus increases endometrial cancer risk. 3. Beginning HT after age 60 increases the risk of coronary artery disease. 4. HT increases the risk of stroke at least for the first one to two years of use. 5. HT for menopausal symptoms should use the lowest effective doses for the shortest possible time. HT includes the use of estrogen alone or the use of estrogen combined with progesterone. It can improve health-related quality of life by improving vasomotor and atrophic vaginitis symptoms caused by menopause. Routine use of HT decreased when research, including the Women’s Health Initiative (WHI), revealed greater than expected risks associated with HT for the subjects in their study. However, it remains an acceptable consideration in younger patients before the age of 60 with few risk factors. Impact of HT on Chronic Disease Outcomes Combined estrogen/progesterone Estrogen alone Harms per 10,000 person-yearsHarms per 10,000 person-years Breast cancer 51 CAD 31 Dementia 88 Dementia 63 Gallbladder disease 260 Gallbladder disease377 Stroke 52 Stroke 79 DVT 120 DVT 77 Incontinence 562 Incontinence 885 Benefits per 10,000 person-yearsBenefits per 10,000 person-years Diabetes-78 Diabetes-134 Fractures-230 Fractures-388 Breast cancer-52 Colorectal cancer-34 Table adapted from: Gartlehner G, Patel SV, Reddy S, Rains C, Schwimmer M, Kahwati L. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022;328(17):1747-1765. How to Decide When to Use Hormone Therapy Hormone therapy can be a helpful treatment for the symptoms of hot flashes and it will help delay bone loss, but it can increase the risk of breast cancer, heart attack, stroke, DVT, and incontinence. Whether or not to use HT can be a difficult decision and therefore must be individualized for each patient. There is no right answer for all patients. Our role as providers is to use the best evidence we have to help patients identify their own unique risks for adverse effects from HT. Then, we can help the patient weigh the potential benefits against her personal risks. Risk factors to consider include: 2026 Aquifer, Inc. – Maureen Francis (mfrancis050@usuniversity.edu) – 2026-03-30 20:25 PDT 5/9 Age Family and personal history of heart disease, stroke, breast cancer, blood clots, or osteoporosis Medications Quality of life plays a large role in this decision. How bothersome are the menopausal symptoms? What are the patient’s preferences regarding prescription medication versus herbal supplements or other strategies? What are their fears? Shared decision-making: In these situations where there is no right answer, the role of the clinician is more of a counselor and to provide information. The responsibility of decision-making shifts to the patient, as only they can balance their quality of life against the risks they are willing to accept. In general, HT for menopausal symptoms should use the lowest effective doses for the shortest possible time, which means we should regularly discuss the risks and benefits of continuing the therapy with patients. Osteoporosis Treatment Bisphosphonates are potent inhibitors of bone resorption and reduce bone turnover, resulting in increased bone mineral density. Bisphosphonates have been shown to decrease the risk of vertebral and nonvertebral fractures. Alendronate (Fosamax) and risedronate (Actonel) are available in generic form, making them more affordable. These can be given daily, monthly orally, or by IV. The total duration of treatment should be 5 years for the oral or 3 years for the IV. Ibandronate (Boniva) is only available by trade name and the cost may be prohibitive to some patients. Zoledronic acid, an intravenous preparation, is given annually and can be used in patients who do not tolerate oral bisphosphonates. Teriparatide (Forteo) is a parathyroid hormone analog and is approved by the FDA for those with osteoporosis at high risk for fracture. It is given subcutaneously and has been shown to decrease fracture risk by 50% to 65%. It does not have demonstrated efficacy and safety beyond two years and is quite costly. Raloxifene is a selective estrogen receptor modulator (SERM) that is used if bisphosphonates are not tolerated but has only been shown to have efficacy in preventing vertebral fractures. Calcitonin binds to osteoclasts, thereby inhibiting bone reabsorption. It has been shown to reduce vertebral fractures, but not hip or other fractures. For most patients, more effective treatments are available. Denosumab is an alternate second-line therapy for patients at high risk of osteoporotic fracture. It inhibits osteoclast formation and survival thereby reducing bone resorption. It is administered in an IV infusion every 6 months and is very costly. Management of Hot Flashes Hormone therapy still has a role in the treatment of hot flashes and other menopausal symptoms in patients at low risk for hormone-related diseases but should be used at the minimum effective dose for the least amount of time, generally 3-5 years although some women will have hot flashes once the HT is stopped. Other prescription medications, including the antidepressants SSRIs and SNRIs, and clonidine and gabapentin, although less effective than HT for vasomotor symptoms, can be beneficial in selected patients. Additionally, fezolinetant was approved by the FDA in 2023 for the treatment of hot flashes and may be an option for some patients. The National Center for Complementary and Integrative Health identified some weak evidence to support the use of hypnotherapy and mindfulness for the management of menopausal symptoms, but outlines specific concerns and recommends against the use of compounded hormones marketed as bioidentical hormone replacement therapy and against the use of DHEA. Furthermore, natural medicines, such as phytoestrogens and botanicals, have not been shown to be clearly safe and effective according to usual standards for prescription medications. Information from The National Center for Complementary and Integrative Health (NCCIH) publication Menopausal Symptoms and Complementary Health Practices: Yoga, tai chi, qi gong, and acupuncture: There is inconsistent evidence to support their effectiveness. Phytoestrogens are found in certain plants such as soy and red clover: There is inconsistent evidence to support their use and they may be harmful in certain patients, particularly those with cancer. Products made from these plants can act like estrogen in the body, but more research needs to be done before they can be widely recommended for the treatment of menopausal symptoms. They may not be safe for patients at risk for hormonally related diseases. Botanicals such as black cohosh: Black cohosh (Actaea racemosa, Cimicifuga racemosa): A 2012 Cochrane review found no benefit from the use of black cohosh for treating hot flashes. Bioidentical hormone replacement therapy and DHEA: Bioidentical hormone replacement therapy is a marketing term for hormone-containing medicines prepared in special pharmacies. Their content isn’t regulated in the way that prescription medications are, and they have not been tested or approved by the FDA. Their safety cannot be assumed and they lack clear prescribing guidelines. DHEA is sold as a dietary supplement and is metabolized into estrogen and testosterone in the body. It has not been proven to be safe or effective and may increase the risk of hormone-related diseases. 2026 Aquifer, Inc. – Maureen Francis (mfrancis050@usuniversity.edu) – 2026-03-30 20:25 PDT 6/9 Studies Evaluation of Postmenopausal Bleeding Transvaginal ultrasound (TVUS) TVUS may be the most cost-effective initial test in patients at low risk for endometrial cancer who have abnormal uterine bleeding. The TVUS will tell us the thickness of the endometrium. If the endometrium is less than 4 mm (some sources say < 5 mm) on ultrasound, it is reassuring and more workup may not be necessary unless the bleeding continues. Besides endometrial thickening, TVUS may reveal leiomyoma (fibroids) or focal uterine masses, as well as ovarian pathology. Endometrial biopsy Office-based sampling using the Pipelle device has a sensitivity for detecting endometrial cancer in postmenopausal women as high as 99%. An endometrial biopsy will obtain a tissue sample that is sent to Pathology to look for evidence of endometrial hyperplasia or endometrial cancer. Complete blood count A complete blood count might be helpful to demonstrate the absence of anemia and thrombocytopenia. An abnormal result would trigger further systemic evaluation. Thyroid-stimulating hormone level Thyroid disorders may cause abnormal uterine bleeding and are associated with an increased risk for endometrial cancer. We assess thyroid function via an inexpensive blood test for thyroid-stimulating hormone (TSH). Clinical Reasoning Differential of Abnormal Uterine Bleeding Most Important/Most Likely Diagnoses Cervical polyps Most common in postpartum and perimenopausal patients; rare in premenstrual and postmenopausal patients. Although cervical polyps are rare in postmenopausal patients, they can occur and may present with vaginal bleeding. Endometrial hyperplasia With or without atypia can cause bleeding. Simple hyperplasia progresses to cancer in less than 5% of patients; atypical complex hyperplasia is a premalignant lesion that has a 25% probability of progressing to cancer. Therefore, careful monitoring and treatment is important with this disorder. Hormone producing ovarian tumors Rare Most ovarian cancers do not cause postmenopausal bleeding or other significant symptoms, but postmenopausal bleeding is one of several symptoms associated with a higher risk for ovarian cancer (6.6-fold increased risk). Other possible symptoms of ovarian cancer include pelvic or abdominal pain, an increase in abdominal size or bloating, and early satiety. Endometrial cancer The fourth most common cancer in patients with uteri , and the main “can’t miss” diagnosis that must be considered in patients presenting with postmenopausal bleeding. Must be considered in patients over the age of 35 with symptoms suggestive of anovulatory bleeding (spotting, menorrhagia, metrorrhagia). Ninety percent of patients with endometrial cancer have abnormal vaginal bleeding. Proliferative endometrium Normal response to estrogen stimulation in premenopausal patients. Occasionally, postmenopausal patients, particularly those in higher estrogen states, can produce a similar endometrial response. On biopsy, this condition may be hard to differentiate from simple hyperplasia. Other possible causes of abnormal uterine bleeding Other possible causes of abnormal uterine bleeding across the age spectrum are medications (including anticoagulants, selective serotonin reuptake inhibitors, antipsychotics, corticosteroids, and hormonal medications) and disorders involving the thyroid, hematologic, hepatic, adrenal, pituitary, and hypothalamic systems. Cervical cancer may also present with vaginal bleeding, although light spotting would be most common. write another essay of the summary.
- One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
- Brief introduction of the case
- Identification of the main diagnosis with supporting rationale
- Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
- Diagnostic plan with supporting rationale or references
- A specific treatment plan supported by recent clinical guidelines
- Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.
