Definition

Postmenopausal bleeding is vaginal bleeding that occurs one year or more after the last menstrual cycle. Menopause is a stage in a woman's life where reproductive hormones decrease and monthly menstrual cycles cease, typically happening at age 50 or above.

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Vaginal bleeding that occurs more than a year after the last menstrual cycle is not normal. The bleeding can range from spotting to heavy bleeding. This condition affects about 10% of women over the age of 55.

Causes

Postmenopausal bleeding is usually caused by benign conditions like uterine polyps. However, in about 10% of women, postmenopausal bleeding is a sign of uterine cancer (endometrial carcinoma).

Other causes of bleeding or spotting after menopause include:

• Uterine or vaginal atrophy (thinning and drying of the uterine or vaginal lining). This condition can cause inflammation in the vagina or the inner lining of the uterus due to decreased estrogen levels
• Hormone replacement therapy, such as estrogen and progesterone supplements used to reduce certain menopause symptoms
• Endometrial hyperplasia (thickening of the inner lining of the uterus, which may contain abnormal cells). This can be caused by hormone replacement therapy, high estrogen levels, or being overweight. This condition can evolve into uterine cancer
• Uterine or cervical polyps (benign tissue growths)
• Ovarian cancer
• Cervicitis or endometritis (infection or inflammation of the cervix or uterus)
• Bleeding from other areas near the vagina, such as the bladder, rectum, or vulva (external genital area)

Risk Factor

Anyone can experience vaginal bleeding, especially during perimenopause. Perimenopause is the transition to menopause, usually occurring between ages 40 and 50, marked by changes in female hormone levels and menstrual cycles.

Diagnosis

To identify the cause of the bleeding, the doctor will examine the vagina and cervix using a tool to open the vagina, allowing visibility of the internal areas. Additional examinations that may be performed include:

• Pap smear to examine cervical cells.
• Ultrasound (usually from the vagina) to detect abnormalities.
• Endometrial biopsy (sampling the inner lining of the uterus). In this procedure, the doctor gently inserts a small tube into the uterus to collect a cell sample to check for abnormal cells.

Management

The management of postmenopausal bleeding depends on the underlying cause. The most common treatments include medication and surgery.

Medications that may be used include:

• Antibiotics: To treat most cases of cervical or uterine infections.
• Estrogen: To help with bleeding caused by vaginal dryness. Estrogen can be applied directly to the vagina as a cream, ring, or tablet inserted into the vagina. Systemic estrogen therapy, in the form of pills or patches, involves estrogen circulating throughout the body.
• Progestin: A synthetic form of the hormone progesterone, progestin can be used to treat endometrial hyperplasia by inducing the shedding of the uterine lining. It can be administered as pills, injections, creams, or intrauterine devices.

Surgical options include:

• Hysteroscopy: A procedure to examine the cervix and uterus using a camera. The doctor will insert a hysteroscope (a thin tube with a light) into the vagina to remove polyps or other abnormal growths that may be causing bleeding.
• Dilation and curettage (D&C): A procedure to take samples from the lining and contents of the uterus. D&C can be performed with hysteroscopy and can also treat certain types of endometrial hyperplasia.
• Hysterectomy: A surgery to remove the uterus and cervix. A hysterectomy may be necessary if you have uterine cancer. The doctor can explain the various techniques for uterus removal, some of which are minimally invasive, requiring only very small incisions.

Complications

The complications of postmenopausal bleeding depend on the underlying cause.

With vaginal atrophy, though not dangerous, it can lead to decreased quality of life, sexual intimacy, and self-confidence. The loss of vaginal elasticity can cause the vagina to become narrower and shorter. Fragile vaginal tissue can tear and bleed.

If the cause is cancer, the prognosis depends on the type of cancer and its stage at diagnosis. The five-year survival rate is 82%.

Prevention

Postmenopausal bleeding can be a benign condition or caused by something more serious like cancer. Although you cannot prevent abnormal vaginal bleeding, you can seek medical help promptly to get a diagnosis and treatment. Early cancer diagnosis can improve survival rates. To prevent postmenopausal bleeding, you can:

• If you have uterine atrophy, seek early treatment to prevent it from progressing to cancer.
• Regularly visit your gynecologist.
• Maintain an ideal body weight, follow a healthy diet, and exercise regularly.
• If recommended by your doctor, consider hormone replacement therapy, which may help prevent uterine cancer. However, be sure to discuss the potential side effects with your doctor.

When to See a Doctor?

Postmenopausal bleeding can be a benign condition or caused by something more serious like cancer. Although you cannot prevent abnormal vaginal bleeding, you can seek medical help promptly to get a diagnosis and treatment. Early cancer diagnosis can improve survival rates. To prevent postmenopausal bleeding, you can try the following steps:

• If you have uterine atrophy, seek early treatment to prevent it from progressing to cancer.
• Regularly visit your gynecologist.
• Maintain an ideal body weight, follow a healthy diet, and exercise regularly.
• If recommended by your doctor, consider hormone replacement therapy, which may help prevent uterine cancer. However, be sure to discuss the potential side effects with your doctor.

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