Postmenopausal Bleeding Is Always a symptom that needs to be evaluated by a Healthcare Provider

Menopause is the time of a woman’s life when she stops menstruating permanently. It is confirmed by missing your period for 12 months. The average age of menopause is 51 years, but the normal range is 45 years to 55 years. Bleeding or spotting after this point is called postmenopausal bleeding (PMB). Postmenopausal bleeding always needs to be check out by a healthcare provider. Many times it can be due to a minor health issue; but it can also be a sign of more serious disease like cancer in the uterus or vagina. If found early many of these cancers can be successfully treated. 

The years leading up to this point are called perimenopause. This is the time that leads up to menopause. This phase can last for up to 7-10 years. During perimenopause, shifts in hormone levels can affect ovulation and cause changes in the menstrual cycle (women can skip periods for months; or bleed too often). Bleeding less than 21 days from the beginning of one cycle until the beginning of the next, bleeding longer than 8 days at a time,  bleeding through a pad and hour, or bleeding after sex are also problems that need a medical evaluation- but these are not the intended focus of this article.

Causes of Postmenopausal bleeding

Most of the time, postmenopausal bleeding is caused by noncancerous conditions:

• inflammation and thinning of the lining of your vagina (called atrophic vaginitis)
• thinning of the lining of your uterus
• growths in the cervix or uterus (called polyps) which are usually not cancerous. Polyps are usually noncancerous growths that develop from tissue similar to the endometrium, the tissue that lines the inside of the uterus. They either attach to the uterine wall or develop on the endometrial surface. They may cause irregular or heavy bleeding. Polyps also can grow on the cervix or inside the cervical canal. These polyps may also cause bleeding after sex.
• thickened endometrium (called endometrial hyperplasia) often because of hormone replacement therapy (HRT). In this condition, the lining of the uterus thickens. It can cause irregular or heavy bleeding. Endometrial hyperplasia most often is caused by excess estrogen without enough progesterone. In some cases, the cells of the lining become abnormal. This condition, called atypical hyperplasia, can lead to cancer of the uterus. When endometrial hyperplasia is diagnosed and treated early, endometrial cancer often can be prevented. 
• abnormalities in the cervix or uterus

These are generally not serious problems and can be cured relatively easily.

However, about 10% of the time, post-menopausal bleeding is linked to cancer of the cervix or uterus and so it is very important to have it checked.

What will happen at the appointment when I am evaluated for PMB?

• Your Healthcare provider will do a detailed history
• Pelvic exam
• Pelvic ultrasound which can measure how thick the lining of the uterus is (the endometrium). An endometrium <4mm suggests likelihood of cancer is low in the uterus and then nothing further may need to happen unless you have a second bleeding episode
• Possible endometrial biopsy with a small pipelle inside the uterus to sample the tissue and suck up cells 

How is PMB treated? Treatment depends on what the suspected cause is:

• Atrophic vaginitis and thinning of the endometrium are usually treated with medications that release estrogen into the vaginal tissues. These medications are safe for most women and don’t carry the risks of taking estrogen systemically (by mouth). These can come as a tablet, vaginal gel or creams, or a soft flexible ring which is put inside your vagina and slowly releases the medication.
• Polyps are usually removed with surgery. Depending on their size and location and your medical history, they may be removed in the office. 
• Thickening of the endometrium is usually treated with medications that work like the hormone progesterone to reverse the thickening.
• A hysteroscopy is a surgical procedure that allows a direct look inside your cervix, uterus and endometrium. A sample or biopsy of your endometrium may also be taken for testing.  A hysteroscopy involves putting a long, narrow instrument (called a hysteroscope) into your uterus through your vagina.  It can be done under local or general anaesthetic. This is done by a gynecologist and can be done in our office under local anesthetic. 
• A dilation and curettage (D&C) to scrape away part of your endometrium and test it. This is done under a general anaesthetic.
• Endometrial cancer is treated with surgery (usually hysterectomy with removal of nearby lymph nodes) in most cases. If found early many times this can be treated with surgery only. Sometimes radiation therapy is also added.

Michelle Liddy, CNM, MSN - Hibiscus Women’s Center