Menses occur during reproductive age, from age 9-12 to 48-52. Most women don't have any problems throughout their reproductive age. However, some may have troubled times with irregular or protracted bleeding. In another scenario, some women have problems after age 50, when their menses have already stopped. In these older women, even though they are in the menopausal age, they still get occasional bleeding which is abnormal. This can happen in women aged after 60 even when on their Hajj pilgrimage. These women are unusually frightened and even though they may feel 'young once again', they do not understand the underlying grave problems and often chose to ignore it, thinking they may possibly have 'another child' in their old age. What is the cause of the bleeding in post-menopausal women? Let's find out.
RESOURCES
Background reading
Uterus-Endometrium-Cancer
Image gallery
anatomy diagrams
menstrual dysfunction
squamous atrophy of the cervix
cervix cytology - atrophy
rectocele (rectal hernia)
grade 3 cystocele (dropped bladder)
cystocele in vaginal prolapse
stress urinary incontinence
uterine prolapse
vaginal prolapse
hysterectomy
vaginal prolapse repair
female pelvic organ prolapse
vaginal rejuvenation
atrophic endometrium and lymphatics
Patient education
http://www.dronuma.com/leaflets.html
Self-assessment
http://www.studyblue.com (UI/Pelvic prolapse/Menopause)
CASE STUDY
Trigger 1: Introduction
An elderly lady named Mek Ameh went of the annual Hajj pilgrimage with Tabung Haji. She felt happy and accepted into the group of women in her tent at Mina. Though tired from the Hajj rites, she was able to obtain sufficient rest and reflected on her fortitude at being 'invited' on the Hajj. She went to the women's area to bathe and perform ablution before her zohor prayer. However, she returned to her tent, a bit worried and decided to talk to her friends in the same tent. It transpired that Mek Ameh was already a menopausal lady aged 65. She had a bleeding a few months before coming on the Hajj trip. This is her second vaginal bleeding, and the first at Mina. She was upset that she might not get to complete her Hajj rite altogether. So she and her friends approached 'Doktor Ustazah' about her postmenopausal bleeding problem at the Tabung Haji clinic in Mina.
Trigger 2: Examinations and Investigations
From her medical history, Mek Ameh first experienced bleeding when she was 12 (tamat sekolah rendah). She married at 13 and had 15 children but three of her children died young. Her last bleeding was eight years after she had her last child, now aged 23. Then she had no more periods until one occurred just prior to the Hajj months. Despite experiencing that one bleeding, she did not feel compelled to see a doctor about it but came on the Hajj trip with her friends. She has no relevant past medical and surgical history and was not on any hormonal treatment.
She was obese. Her vital signs were stable.
A blood specimen was taken for analysis by the Hematology laboratory.
Another blood specimen was taken for analysis by the Chemical Pathology laboratory.
Pelvic exam: Vulva, vagina and cervix were atrophic. Brownish stained discharge was noted. There was cystocoele and rectocoele. There was mild descent of the cervix. Uterus was 10 weeks size. A cervical smear was sent to the Pathology laboratory.
A pelvic ultrasound was arranged for her.
She was admitted for a day at the Gynae Day Ward. A hysteroscopy and diagnostic dilatation & curretage (DD&C) were ordered for her.
Trigger 3: Results
The results of her investigations were as follows:
Hb: 11.4%
Platelet count: 210 x 10**9/L]
Random Blood Sugar (RBS): 4.6 mmol/L
Cervical smear: Normal
Pelvic Ultrasound: Uterus was uniformly enlarged. Endometrium was 1.5 cm thick. Ovaries were atrophic.
Hysteroscopy and diagnostic dilatation & curretage (DD&C) returned the following diagnosis: Adenocarcinoma of the endometrium
Mek Ameh was called to the Tabung Haji clinic and counseled regarding her condition and treatment.
She successfully completed the Hajj and returned to Malaysia.
In Malaysia, she underwent total abdominal hysterectomy and bilateral salpingo-oopherectomy.
She recuperated and lived a disease-free life once again. She felt liberated.