Postmenopausal Bleeding and its Causes

Postmenopausal bleeding is the condition in which uterine bleeding occurs after a female has gone through menopause. While some bleeding is common during the perimenopausal time frame, uterine bleeding after menopause is unusual and should be evaluated by a gynecologist upon initial detection.

Generally, menopause occurs between the ages of 45-55, with the average age being 51. The transition into menopause can range anywhere from a few months to several years, though the average duration is 3-4 years. The postmenopausal period can generally be defined as the time after which the symptoms of menopause have subsided.

The severity of postmenopausal bleeding ranges greatly, from minor spotting to heavy flows, though it doesn’t tend to result in any pain. No matter the level of bleeding that occurs, however, a gynecologist should be informed, and an appointment for screening and examination should be scheduled.

Causes of Postmenopausal Bleeding

Normal uterine bleeding occurs during the reproductive years of a woman’s life during the menstrual cycle, yet bleeding occurring after menopause is not a natural event and should be concerning to any female.

Bleeding at this stage is more likely to be caused by an abnormal condition versus something simple. So, it’s important to evaluate the problem early instead of waiting to see if the problem goes away without any intervention.

The following are the most common causes of postmenopausal uterine bleeding:

• Endometrial Polyps
• Endometrial Hyperplasia (the thickening of the uterine wall)
• Endometrial Atrophy (the thinning of the uterine wall)
• Fibroids
• Endometrial Cancer
• Cervical Cancer
• Blood Thinners may be a contributing factor to postmenopausal bleeding

Another possible cause of postmenopausal bleeding is vaginal irritation due to the lack of estrogen, which is referred to as vaginal atrophy. Some postmenopausal women experience pain and bleeding resulting from sexual intercourse.

Diagnosis of Postmenopausal Bleeding

Any bleeding during the postmenopausal time must be evaluated as soon as possible. The most important concept in the diagnostic evaluation of postmenopausal bleeding is ruling out cancer. A transvaginal ultrasound will likely be performed, which will help determine if a uterine polyp, mass, or thickened uterine lining is present. This can be followed by a subsequent procedure involving dilation of the cervix and sampling of the endometrium or removal of a mass or polyp.

The endometrial biopsy will show either endometrial hyperplasia or endometrial cancer. It’s important to note that endometrial hyperplasia can progress to endometrial cancer or can be an indicator of coexisting endometrial cancer.

Available Postmenopausal Treatment

The treatment prescribed will be determined by the primary cause of bleeding.

If the bleeding is caused by endometrial hyperplasia, the treatment can be either treatment with progestin therapy or hysterectomy. The recommendations by the OB-GYN will depend upon associated risk factors. For example, some patients want to avoid surgery and may be appropriate candidates for progestin. Yet, some will want to have definitive care, which both eliminates the source of bleeding as well as the risk of cancer.

Endometrial cancer will require surgery during which the process of surgical staging will be done. The surgical procedure will involve the removal of the uterus, fallopian tubes, ovaries, and surrounding lymph nodes which determines the level of spread of cancer. The surgical procedure is often performed as a “robotic” or laparoscopic procedure, which is the standard minimally invasive surgical technique. This type of surgery has the least morbidity for patients.

There are some additional treatment considerations in cases of postmenopausal bleeding caused by diagnoses other than endometrial cancer or endometrial hyperplasia.

The following are the most common treatments of other postmenopausal bleeding causes:

• Postmenopausal Hormone Therapy – depending on the individual situation
• Surgical Removal of Polyps
• Hysterectomy

Hysterectomy is an appropriate consideration in cases where attempted conservative therapy for postmenopausal bleeding has failed. The hysterectomy procedure should include the excision of the fallopian tubes and ovaries to prevent any possible development of cancer in those tissues. In addition, a vaginal hysterectomy may be considered in women who are appropriate candidates. Minimally invasive surgery utilizing laparoscopic-assisted hysterectomy or robotic surgery can also be considered in this case.

The ultimate goal of any treatment is to eliminate symptoms, cure the problem, and minimize the potential risks. Your gynecologist will help to determine what course of treatment is best.

Final Thoughts

Postmenopausal bleeding is usually unexpected and can be quite concerning for women. However, timely and effective treatment will lead to the best possible outcome for postmenopausal bleeding. When symptoms begin, be sure to see your medical care professional or gynecologist at the earliest possible time. Early detection of the cause of bleeding will definitely lead to better overall health.

Postmenopausal bleeding is not normal and must be taken seriously. While it may not cause pain, it should not be ignored. The bleeding can often worsen, and it may also be a sign of a more significant health issue such as cancer.

An evaluation by a gynecologist is the standard of care for this medical condition.