What is Postmenopausal Bleeding?
Menopause is a stage in a woman’s life when her menstrual cycles end completely. This usually happens when her ovaries no longer have any egg-producing follicles left. Generally, a woman is considered to be in menopause if she hasn’t had a period for a whole year. In the US, most women reach menopause around the age of 51. If a woman experiences bleeding after she has gone through menopause, it’s out of the ordinary and is considered a problem. This kind of post-menopause bleeding is the reason why about two-thirds of postmenopausal women have to visit the gynecologist’s office.
There are several conditions that can cause postmenopausal bleeding (PMB). The most common cause is the thinning and drying out of the tissues in the lower part of the reproductive system. However, it’s important to note that 90% of postmenopausal women who are diagnosed with endometrial cancer (cancer of the lining of the uterus) initially presented with vaginal bleeding. Like with many types of cancer, the chances of successful treatment are much higher if endometrial cancer is diagnosed early. Therefore, any woman who is postmenopausal and has vaginal bleeding should be seen by a healthcare professional right away. Tests, including sampling the tissue of the uterus (endometrial biopsy) and imaging, may be required. The course of treatment will largely depend on what is found to be causing the bleeding.
Healthcare professionals need to have a solid understanding of PMB due to its commonality. This includes being able to choose the right diagnostic tests, knowing how to manage treatment based on the identified cause, and working as part of a team with other healthcare professionals to ensure the best outcome for the patient.
What Causes Postmenopausal Bleeding?
Postmenopausal bleeding (PMB) is sometimes incorrectly thought of as normal menstruation by women who haven’t had a menstrual period for over a year. However, this bleeding can also originate from other areas, such as the urethra, vulva, vagina, cervix, or rectum. The most frequently seen cause of postmenopausal bleeding is the thinning or shrinking of genital and urinary organs, which is responsible for about 60% of cases.
The source of postmenopausal bleeding could also be from other areas not related to female reproduction, like the urethra, bladder, or digestive tract, and can be falsely identified as vaginal bleeding. There are several potential causes of postmenopausal bleeding, including:
– Thinning or inflammation of the vagina or uterus lining
– Infections in the female genital and urinary systems, such as inflammation of the uterus lining, vagina, bladder, or cervix, caused by illnesses like tuberculosis
– Certain medications, like estrogen, tamoxifen (a drug used in breast cancer treatment), and drugs that prevent blood clotting
– Noncancerous growths in the uterus called uterine fibroids
– Cancers in the female genital tract
– Foreign objects stuck in the vagina
– Growth of noncancerous masses, called polyps, in the uterus lining
When genital and urinary organs shrink or thin out, this can lead to an abnormal increase in cells in the uterus lining, sometimes with changes in the cells themselves.
Risk Factors and Frequency for Postmenopausal Bleeding
Vaginal bleeding is experienced by up to 10% of women after menopause and is the main reason behind about two-thirds of gynecological doctor visits for these women. Initially, around 40% of women experience bleeding per year when menopause starts. However, this lowers to about 4% per year three years after menopause.
Endometrial cancer, which is a type of uterine cancer, is the fifth leading cause of cancer-related death in the U.S and is the fourth most common cancer in women. It accounts for 92% of all uterine cancer cases. Moreover, over 90% of women after menopause who have endometrial cancer first notice it due to this type of bleeding. In contrast, in women under the age of 50, less than 1% of this bleeding is because of endometrial cancer. However, the likelihood of bleeding due to endometrial cancer increases to 24% in women who are older than 80.
With obesity and late menopause being risk factors, the total number of endometrial cancer cases worldwide is on the rise. Predictions say that the number of people diagnosed with endometrial cancer may double by the year 2030.
Signs and Symptoms of Postmenopausal Bleeding
Postmenopausal bleeding (PMB) requires a comprehensive history check to both understand possible causes and confirm a patient’s menopausal status. The main priority of the evaluation is to rule out harmful causes, such as endometrial cancer. Here are a few things medical professionals might ask about:
- Current symptoms: Information about any ongoing bleeding and other linked symptoms can help identify potential causes. It is important to ask about things like the onset, duration, heaviness, and possible triggers of the bleeding. Other signs like fever, pelvic pain, burning during urination, hot flashes, sexual discomfort, and vaginal dryness are also useful.
- Past medical history: Conditions like obesity, polycystic ovarian syndrome, diabetes, thyroid disease, pelvic infection, or clotting disorders could cause abnormal bleeding. Other factors like radiation exposure might be relevant too.
- Menstrual history: Detailed information about past menstrual cycles can help determine whether a patient is postmenopausal. Early periods (before 12 years of age) or late menopause (after 55) may increase the risk of endometrial cancer. Recent cervical or endometrial screenings may also be significant.
- Surgical history: Past surgeries can offer clues about causes of vaginal bleeding. Some surgeries may also lead to menopause.
- Social history: Factors like genitourinary infections or smoking could also be relevant. Smoking raises the risk of bladder cancer, mesh erosion, and blood in urine, all of which could cause bleeding.
- Family history: Cancer history in a patient’s family, along with inherited mutations that increase endometrial cancer risk, should be explored.
- Medications: Some medications and supplements can affect endometrial lining, leading to bleeding in postmenopausal women. These include hormone replacement therapy, tamoxifen, anticoagulants, and certain herbal supplements.
During a physical check-up, the doctor will examine both the internal and external parts of the genital tract. The exam might reveal bleeding sites, genital lesions, lacerations, urethral prolapse, and signs of atrophy, such as pale, dry vaginal tissue with fewer wrinkles. Swelling, tiny spots of redness, fragility, and discharge could indicate inflammation. The doctor may also feel for pelvic masses, abdominal distention, and enlarged lymph nodes.
Testing for Postmenopausal Bleeding
Studies done by the doctor are crucial in assessing postmenopausal bleeding (PMB), with the main goal being ruling out the possibility of the thickening of the endometrium (inner lining of the uterus) or cancer in the endometrium. The American College of Obstetricians and Gynecologists (ACOG) suggests starting the assessments with one test, transvaginal ultrasound or endometrial biopsy, in low-risk women. But for those with risk factors for endometrial cancer or recurring PMB, an endometrial biopsy is the recommended initial test. Lab testing could also be ordered to evaluate possible issues resulting from heavy vaginal bleeding and to rule out other possible diagnoses.
An endometrial biopsy involves taking a sample from the endometrium for analysis to identify possible malignancies or warning signs. It’s recommended for different scenarios including continuing or returning bleeding PMB despite having a thin endometrial stripe on ultrasound, risk factors for endometrial cancer such as obesity, smoking, or exposure to unopposed estrogen, endometrial lining thickness of more than 4mm in a woman with PMB, and if endometrium is not clearly seen on imaging studies.
Diagnosis with endometrial biopsy proves accurate. However, it occasionally fails, especially when not enough tissue is obtained, and in those cases, follow-up ultrasound may be needed. Further assessment is unnecessary if the follow-up ultrasound shows a thin endometrial stripe and if the vaginal bleeding ceases.
Transvaginal imaging is another initial modality used alongside endometrial biopsy that measures the thickness of the endometrial lining in patients without a need for tissue analysis. A thickness of 4mm or less is a strong indicator that endometrial cancer is unlikely. Despite its effectiveness, endometrial imaging can’t diagnose conditions, and does not always signify the absence of disease. So, even if the endometrial lining is 4mm or less, an endometrial biopsies should be done for cases of continuing or returning PMB.
If the endometrial stripe is thickened, it might be because of possible issues such as the thickening of the endometrium, cancer, and growths in the uterus (eg, leiomyomas and endometrial polyps). If this is the case, more imaging may be needed. Additionally, if the ultrasound suggests growths in the uterus or if the patient has a medical history that suggests them (eg, history of polyps), advanced imaging techniques such as saline-infused ultrasonography or hysterosalpingogram could be used. In some instances, a pelvic CT or an MRI might be used.
Hysteroscopy with dilation and curettage is considered as the best diagnostic method because it allows for both the sampling and removal of certain causes of PMB, such as polyps, at the same time. If regular biopsy procedures fail to get a sufficient sample or if there are continuing symptoms of vaginal bleeding, further imaging tests could be needed. Procedures such as hysteroscopy with dilation and curettage or directed biopsy may be recommended by your provider.
Moreover, lab tests, including complete blood counts (CBC), thyroid-stimulating hormone (TSH), and clotting studies may be required to help rule out other differential diagnoses and assess for secondary issues due to abnormal bleeding. For women who’ve gone through early menopause (ie, older than 40), a routine pregnancy test is usually performed. A Papanicolaou test, also known as a Pap smear is normally not used for diagnosis, but it can hint at the potential causes of PMB like cervicitis, sexually transmitted diseases, and cervical and endometrial cancers.
Treatment Options for Postmenopausal Bleeding
Treatment for PMB (post-menopausal bleeding) primarily addresses the root cause of the issue. However, other factors are also considered such as the patient’s overall health, preferences and specific characteristics of the bleeding (like how heavy it is and how long it lasts).
Here are some common causes of PMB and how they’re typically managed:
Genitourinary atrophy: The bleeding will usually stop on its own and may not require any treatment. Dryness in the vagina, a common symptom, can be treated with non-hormonal moisturizers and lubricants. Topical estrogen can effectively manage symptoms of vulvar and vaginal atrophy and is often the first choice of treatment. Oral hormone replacement and hormonal receptor modulators can also be used as alternatives if other treatments did not yield significant improvements.
Endometrial polyps: These are a common cause of PMB but they often do not cause any symptoms. The severity of the bleeding does not depend on the number or size of the polyps. Despite this, because endometrial polyps can sometimes be cancerous, healthcare professionals often recommend removing them for further examination, especially if the patient has a higher risk for cancer.
Uterine leiomyoma (fibroids): These are generally benign and get smaller with menopause. Depending on the patient’s symptoms, medications, or surgeries like myomectomy and hysterectomy (the removal of the uterus), may be considered. Every situation is unique, so proper counseling and shared decision-making are essential.
Genitourinary Infections: If a patient has a sexually transmitted disease or other genital infection, the treatment will depend on the results of a vaginal culture test. Doctors may recommend oral doxycycline to treat endometritis, an inflammation of the inner lining of the uterus.
Cancer in the cervix, vagina, and vulva: Surgery and chemoradiotherapy depend on the stage of the cancer.
Endometrial hyperplasia or cancer: Hyperplasia, the abnormal increase in cells, can be treated through a variety of ways depending on factors such as other health conditions the patient may have. Endometrial cancer, on the other hand, usually requires surgical treatment.
Benign endometrial hyperplasia: More commonly known as nonatypical endometrial hyperplasia, this is usually managed through hormonal therapy.
Endometrial intraepithelial neoplasia: The treatment would depend on several factors including patient’s preferences. In postmenopausal women, minimally invasive hysterectomy is commonly performed. If surgery is not an option, medication is also an acceptable course of action but must be accompanied by frequent checks.
Endometrial adenocarcinoma which is a type of cancer, is usually treated with a hysterectomy and comprehensive staging to determine the stage of the cancer and formulate an appropriate treatment plan.
Hematuria: This refers to the presence of blood in urine, which can also be caused by genitourinary atrophy. If there’s an underlying bacterial infection causing bladder inflammation (cystitis), antibiotics may be recommended.
Gastrointestinal bleeding: Sometimes, the presence of blood can be mistaken for vaginal bleeding. The treatment for this depends on the cause and may range from surgery to anti-inflammatory medications or antibiotics.
Medications like hormone replacement therapy and anticoagulants can cause PMB as a side effect, in which case a medical professional would evaluate the need for those medications compared to their side effects and discuss options with the patient.
What else can Postmenopausal Bleeding be?
Doctors who are evaluating patients with postmenopausal bleeding (PMB) need to consider other conditions that may look a lot like PMB. These could be related to parts of the body outside the reproductive system, like the urethra (the tube that lets urine pass out of the body), bladder, or gastrointestinal (GI) tract, which includes your stomach and intestines. Or they could be tied to the reproductive system. Some common conditions that doctors should think about when evaluating postmenopausal bleeding include:
- Infections in the urinary and sexual organs, like endometritis, vaginitis, cystitis, or cervicitis
- Uterine leiomyomas, which are non-cancerous growths in the uterus
- Cancers in the genital tract
- Foreign objects in the vagina
- Conditions affecting the gastrointestinal system, such as diverticulitis, colitis, hemorrhoids, or cancer
- Genitourinary atrophy, which refers to the thinning of the walls of the vagina and urethra
- Damage caused by radiation to nearby organs, like hemorrhagic cystitis (inflammation of the bladder), proctitis
(inflammation of the lining of the rectum), or necrosis (cell death)
The doctor must carefully consider these other conditions and run the necessary tests to get an accurate diagnosis.
What to expect with Postmenopausal Bleeding
Generally speaking, PMB (postmenopausal bleeding) has a positive outlook, as the most common causes are harmless and treatable. Moreover, the most common serious cause of PMB, endometrial cancer, actually has a better outlook than most other cancers. In fact, the five-year survival rate of endometrial cancer is about 90%.
It’s worth noting that, in patients diagnosed with endometrial hyperplasia (thickening of the uterus lining), who then have a hysterectomy (surgery to remove the uterus), about 43% are found to have previously undiagnosed endometrial cancer.
Possible Complications When Diagnosed with Postmenopausal Bleeding
The main complication of PMB (postmenopausal bleeding) is anemia, which is when your body doesn’t have enough red blood cells. This affects around 10% of women after menopause. There can be other complications, but they usually relate to what is causing the bleeding in the first place. For example, genitourinary atrophy (when the reproductive and urinary systems start to naturally decline) can make a woman’s life worse, leading to issues with sexual intimacy and self-esteem. Uterine fibroids (non-cancerous growths of the uterus) can lead to discomfort in the pelvis.
The treatments for the causes of PMB can also have their own side effects. For instance, a medication called megestrol used to treat endometrial hyperplasia (overgrowth of the lining of the uterus), could lead to weight gain, feelings of sickness, blood clots, and continued vaginal bleeding.
Common Complications and Side Effects:
- Anemia (secondary to PMB)
- Reduced quality of life due to genitourinary atrophy
- Decreased sexual intimacy
- Lower self-esteem
- Pelvic discomfort due to uterine fibroids
- Weight gain from medication
- Nausea from medication
- Blood clots from medication
- Continued vaginal bleeding from medication
Preventing Postmenopausal Bleeding
Healthcare professionals aim to prepare women in the perimenopause phase, the transitional period before menopause, about the expected changes during their menstrual cycles. This stage is often accompanied by various changes in the body. Importantly, women should be informed that any bleeding once menopause is fully established is not normal.
Women should have a clear understanding of when to seek medical help and should be periodically asked about any unusual vaginal bleeding during regular check-ups. Doctors or nurses, often being the first to see patients with perimenopause-related issues, play a vital role in educating them about the risk factors associated with endometrial hyperplasia, which is an abnormal thickening of the lining of the uterus. These risk factors can include obesity and an excess of estrogen in the body without a balancing amount of progesterone.
They also provide preventive treatments, including the use of intrauterine devices (IUDs), which can significantly reduce the risk of uterine cancer by up to 50%. An IUD is a small device that’s placed in the uterus to prevent pregnancy.
