Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Postmenopausal Bleeding


Differential Diagnosis

  • Atrophic endometrium
  • Atrophic vaginitis
  • Blood dyscrasias
  • Cancer of the reproductive organs
  • Endometrial polyps or hyperplasia

Specialists

  • Family Physician
  • Gynecologist
  • Internal Medicine Physician
  • Oncologist

Comorbid Conditions

Factors Influencing Duration

Factors influencing duration include the woman's age and general health, the underlying cause, its treatment, complications, job demands, and response to treatment.

Medical Codes

ICD-9-CM:
627.1 - Postmenopausal Bleeding

Overview

Postmenopausal bleeding is vaginal bleeding that occurs six months or more after menstrual function stops due to menopause. This differentiates it from the irregular, infrequent periods (oligomenorrhea) that occur around the time of menopause, which can last between 1 to 2 years.

There are many conditions that cause postmenopausal bleeding; abnormal vaginal bleeding is a common complaint among women. In general, postmenopausal vaginal bleeding is caused by a hormonal disturbance or lesion in either the cervix or uterine lining (endometrium). The most common causes of upper reproductive system bleeding relate to the wasting or shrinkage of the endometrium following menopause (atrophic endometrium), rapid reproduction of endometrial cells (endometrial proliferation), overgrowth of the endometrium (hyperplasia), endometrial or cervical cancer, uterine tumors, and using estrogen replacement therapy without adding progestin. The most common cause of lower reproductive tract postmenopausal bleeding is inflammation and drying of the vagina associated with menopause and loss of estrogen (atrophic vaginitis); this can be the cause of short term bleeding that occurs after intercourse. Other causes of postmenopausal bleeding include lesions and cracks on the vulva, trauma, growths protruding inside the uterus (endometrial polyps), cervical ulcers caused by prolapse of the uterus, estrogen-secreting tumors in other parts of the body, and bleeding abnormalities. Postmenopausal bleeding from the uterus must be regarded as cancer until proven otherwise.

Incidence and Prevalence: As mentioned, postmenopausal bleeding can be caused by several disorders. The statistics regarding some of these disorders include the following: Cervical cancer is the fourth most common malignant cancer in women (Garcia); and endometrial proliferation occurs in 1 case per 1000 women (Tate).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Women who are obese or taking hormone replacement therapy (HRT) are at risk for postmenopausal bleeding.

Source: Medical Disability Advisor



Diagnosis

History: A detailed history as to how long bleeding has existed, including frequency, length, and quantity of bleeding should be provided to the physician. The woman may report individual episodes of spotting, or she may report days or months of profuse bleeding. Pain may or may not be reported. A history of thyroid, kidney or liver conditions may be reported. She may report a history of bleeding or easy bruising. Medications taken, especially estrogens or steroids, should be disclosed.

Physical exam: The results of physical and pelvic examination will depend on the underlying cause of the postmenopausal bleeding. Examination of the vulva, vagina, and uterus both by visual and palpation exam may reveal signs of atrophy, and areas of bleeding, ulcers, or tumors. A sample of vaginal fluid may be obtained for examination under the microscope and may indicate low estrogen effect. Examination of the cervix may reveal polyps or other lesions. A uterus that is larger than normal may be indicative of the presence of fibroids or polyps or cancer.

Tests: The tests ordered depend on the suspected underlying cause, and can include complete blood count (CBC) and platelet count. Cytologic smears from the vagina may be obtained. A Pap smear and biopsy of the cervix will be obtained. Tests performed to identify abnormalities of the uterus may include endometrial biopsy, and dilation and curettage (D&C). Hysteroscopy may reveal the presence of uterine polyps, atrophy, endometrial hyperplasia, or cancer. Imaging examinations that may be performed include a pelvic sonogram, vaginal probe (transvaginal) ultrasonography to measure the thickness of the endometrium, the injection of liquid into the uterus prior to inserting a vaginal probe (saline infusion sonogram - SIS) to more clearly identify structural abnormalities, CT scan, MRI, or hysterosalpingography.

Source: Medical Disability Advisor



Treatment

Treatment of postmenopausal bleeding depends on the cause. Postmenopausal bleeding due to bleeding from the vagina or vulva can be treated with local application of estrogen (hormone replacement therapy-HRT). Removal of tissue from the inside of uterus (curettage) may be all that is necessary to relieve postmenopausal bleeding. Removal of polyps (polypectomy) will correct bleeding associated with their presence. Cyclic progestin may be administered for treatment of overgrowth of the endometrium (simple endometrial hyperplasia), for up to 3 months. At completion of progestin therapy, a repeat D&C or endometrial biopsy will be performed to verify absence of hyperplasia. Then oral HRT with progestin may be given; most women who are on cyclic HRT, taking estrogen along with progesterone, may experience monthly withdrawal bleeding; this is a normal side effect that does not require treatment. Continuous HRT regimens do not cause monthly bleeds.

Hysterectomy may be necessary to treat endometrial hyperplasia with atypical cells, cancer of the uterus (endometrial), uterine fibroids, and bleeding that does not resolve with treatment (refractory) causing anemia due to chronic blood loss. Cancer of the uterus or cervix may require surgery and / or treatment with anti-cancer medications (chemotherapy) or radiation therapy.

Source: Medical Disability Advisor



Prognosis

Outcome depends on the cause of the bleeding, and can range from complete cure to death from cancer. A simple dilation and curettage (D&C) procedure may completely stop postmenopausal bleeding. Polypectomy will relieve any bleeding associated with the presence of polyps. Endometrial hyperplasia is usually resolved by administering progestin for 3 months. Estrogen replacement therapy (ERT) with progestin usually prevents additional abnormal postmenopausal bleeding. A hysterectomy will permanently cure endometrial hyperplasia with atypical cells, uterine fibroids, bleeding, and anemia. The outcome of a hysterectomy, as treatment of cancer of the endometrium (uterus) or cervix, depends on the extent of tumor spread. The outcome of endometrial and cervical cancers that are diagnosed early is very good.

Source: Medical Disability Advisor



Complications

Profuse bleeding can cause anemia. Prolonged use of estrogen replacement therapy (ERT) that is not combined with progestin increases the risk of endometrial hyperplasia and endometrial cancer in women who have not had a hysterectomy. Cancer, both endometrial and cervical, can spread to other areas of the body.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Time off from work may be needed for tests, and for diagnostic and therapeutic procedures. Work restrictions may be needed if surgery is required. A hysterectomy due to cancer is usually performed through an abdominal incision. Recovery time following hysterectomy may be between six to eight weeks. If chemotherapy is needed, additional time away from work will be necessary, not only for the therapy itself, but for side effects and individual response to the medication.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does the history of postmenopausal bleeding involve individual episodes of spotting, mild bleeding, or was the bleeding profuse, lasting days or months?
  • Was there any pain reported?
  • Did the woman report a history of other conditions such as thyroid, kidney, or liver abnormalities?
  • Was there a history of bleeding or easy bruising?
  • Has the woman been taking anticoagulants, estrogens or steroids?
  • Did examination of the vulva and vagina reveal areas of bleeding, ulcers, or tumors?
  • Did an unstained wet mount in saline and potassium hydroxide reveal the presence of white blood cells, infection-causing organisms, basal epithelial cells (that indicate low estrogen effect)?
  • Did examination of the cervix reveal polyps or other lesions?
  • Did examination of the uterus reveal a uterus that is larger than normal (may be indicative of the presence of fibroids or other tumors)?
  • Did a CBC and platelet count reveal any abnormalities that may contribute to spontaneous bleeding?
  • Did the Pap smear or biopsy of the cervix reveal abnormalities?
  • Were other diagnostic procedures performed such as biopsy, dilation and curettage (D&C), or hysteroscopy? What did they reveal?
  • Were imaging examinations performed such as a pelvic sonogram, transvaginal ultrasonography, CT scan, MRI scan, or hysterosalpingography? What did they reveal?

Regarding treatment:

  • Was aspiration curettage performed for treatment of postmenopausal bleeding?
  • Was polypectomy performed?
  • Was progestin given to treat simple endometrial hyperplasia?
  • Was it effective?
  • Was hysterectomy performed for treatment of endometrial hyperplasia (with atypical cells), cancer of the endometrium, uterine fibroids, anemia or bleeding that didn't resolve with treatment?
  • Was chemotherapy given for treatment of cancer of the endometrium or cervix? Was radiotherapy?

Regarding prognosis:

  • Based on the age, general health and underlying cause of the bleeding, what was the expected outcome?
  • Did individual have any pre-existing conditions that could impact recovery and prognosis? If so, have these conditions been addressed in the treatment plan?
  • Did individual suffer any complications (anemia, etc.) that could prolong disability?

Source: Medical Disability Advisor



References

Cited

Garcia, Agustin A., and Jia Bi. "Cervical Cancer." eMedicine. Eds. John J. Kavanagh, et al. 17 Dec. 2004. Medscape. 22 Feb. 2005 <http://emedicine.com/med/topic324.htm>.

Tate, Susan B., and Charles N. Landen. "Premalignant Lesions of the Endometrium." eMedicine. Eds. Serdar H. Ural, et al. 28 Feb. 2003. Medscape. 22 Feb. 2005 <http://emedicine.com/med/topic3334.htm>.

Source: Medical Disability Advisor






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