Post-Menopausal Bleeding

Postmenopausal bleeding is bleeding pervagina after you have attained menopause and this needs to be checked out by a doctor. Most of the time the cause will be something very simple as vaginal dryness and can be as dreaded as cancer. It is not normal for you to bleed or spot 12 months or more after your last period. You need to see your doctor even if bleeding has only happened once, there's only a small amount of blood, spotting, or pink or brown discharge, even if you don't have any other symptoms and if you're not sure if its blood. When the cause is identified early, most conditions causing bleeding after menopause (including cancer) can be successfully treated.

What is menopause?

The World Health Organization defines natural menopause as the ‘permanent cessation of menstruation resulting from the loss of ovarian follicular activity without an obvious intervening cause and is confirmed only after 12 consecutive months of amenorrhoea (no menstruation)’. In general, natural menopause occurs between 45 & 55 years of age. In Indian women, the range of mean age at menopause reported in different studies appears to be rather early, between 41.9 & 49.4 years. Thus, menopause means complete ceasing of monthly menstrual periods. Since your final menstrual periods before menopause can be very irregularly irregular, menopause is labeled only after 12 months of completely stopping your periods. Thus, menopause is a retrospective diagnosis.

What is postmenopausal bleeding?

Any bleeding or spotting that happens after menopause is known as postmenopausal bleeding. It’s important to remember that it is not normal to bleed or spot 12 months or more after your last period. Causes of postmenopausal bleeding could be simple or serious hence it is always wise to see a doctor.

What causes postmenopausal bleeding?

There are various reasons for postmenopausal bleeding for example:

  1. Women taking hormone replacement therapy (HRT)

  2. Uterine polyps

  3. Endometrial hyperplasia, 

  4. Gyne cancer – cervix, uterus, vagina & vulva and 

  5. Endometrial atrophy.

HRT

Menopause can be a very destressing phase for some women and about 80% of menopausal women will experience some menopausal symptoms. Menopause can have an impact on your quality of care. When alternative treatment fails small proportion of menopausal women take hormone replacement therapy (HRT). One of the long term health problems with HRT is bleeding after menopause.

Uterine polyps

Uterine polyps are noncancerous fleshy growths of the inner lining of the womb. Though noncancerous sometimes these polyps may eventually become cancerous. The only common symptom most patients with polyps will experience is postmenopausal bleeding (but in younger women they can experience irregular bleeding). 

Endometrial hyperplasia 

Endometrial hyperplasia is the multiplying of the cells lining the endometrium (the innermost layer of the uterus) and the endometrium becomes thick. It is one of the common causes of postmenopausal bleeding. This condition is often caused when there is an excess of estrogen hormone without enough progesterone in the body. Progesterone hormone protects the endometrium so, when there are less progesterone and excess of oestrogen the endometrium multiples and causes hyperplasia. This is a precancerous condition for endometrial cancer, It occurs frequently in women after menopause and also seen in women with polycystic ovary syndrome (PCOS). 

Gyne-cancer 

It has been noted that about 10%  of the time, post-menopausal bleeding is linked to cancer. Cancer of the cervix and endometrium is the most common cancer causes for postmenopausal bleeding. Vulval and vaginal cancers are though not as common as cervical and endometrial cancer in the Indian population but these cancers too can present as postmenopausal bleeding. In addition to postmenopausal bleeding theses cancers can also present with pain, urinary & bowel complaints, and bleeding after sexual intercourse (mainly in cervical cancer). Rare type of ovarian tumour such as granulosa cell tumour (hormone-producing tumour) can also lead to postmenopausal bleeding. 

Endometrial atrophy 

Atrophy means dryness so after menopause since there is a decline in hormones the inner lining of the endometrium undergoes atrophy and leads to the endometrial lining becoming too thin. As the lining thins out, bleeding may occur sometimes. 

What are the symptoms?

Bleeding after menopause is the main symptom and many may not have other symptoms. But symptoms may be present. Depending on the cause of bleeding sometimes they can have other symptoms such as pain, bladder and bowel complaints, bleeding after sexual intercourse, bloody white discharge that may be foul-smelling. 

In addition to this since women are undergoing menopause, they can have menopausal symptoms such as 

  • like hot flashes

  • vaginal dryness

  • decreased libido

  • insomnia

  • stress incontinence 

  • increased urinary tract infections 

  • weight gain

How is postmenopausal bleeding diagnosed?

A doctor may conduct a 

Physical examination: This is mainly to rule out any abnormalities on the vulva, vagina, and cervix and medical history analysis. They may also conduct a Pap smear as part of a pelvic exam. An internal examination will be performed to note for any ovarian tumor. 

Transvaginal ultrasound (TVS)

This is an ultrasound procedure done by placing the ultrasound transducer into the vagina. TVS is superior to transabdominal ultrasound (TAS) that’s because when the ultrasound transduced is closer to the pelvic organs imaging is better. TVS will allow doctors to view the ovaries, uterus, and cervix. One of the main things that the doctor would do during this procedure is to measure the endometrial thickness (inner lining of the womb). The endometrial thickness in postmenopausal women should be 4 or less than 4mm.

A pipelle test:

When the endometrial thickness is more than normal then you would be advised to get a sample or biopsy of your endometrium. This can be done without any anesthesia and is done in a day clinic with a thin tube (or pipelle) which is put into your uterus (through your vagina) and gently sucks up a small sample of cells and sent to the lab for histopathological (HPE) evaluation.

Hysteroscopy 

This procedure is direct viewing of the inner lining of the uterus and is done under anesthesia. Here the doctor will insert a small fiber-optic telescope into the uterus through the vagina and cervix to visualise the endometrium. After visualising the lining of the uterus a sample or biopsy of your endometrium may also be taken for testing.  

Dilation and Curette (D&C):

This may be advised in some cases. This is again done under mild sedation. In this procedure, the endometrium is scraped and tested. This is like pipelle biopsy but done a bit differently. 

How is postmenopausal bleeding treated?

In about 90% of cases, an exact cause for postmenopausal bleeding will not be found. Treatment will depend on the cause identified -

  • If you are on HRT: you will be advised to stop the HRT and will be asked to be under close observation. You can discuss alternative treatment for your menopausal symptoms. 

  • Uterine polyp: need to be removed. Depending on the size and location of the polyps, they may be removed as a daycare procedure using a local anesthetic or you may need to get admitted to the hospital to get it done under general anesthesia.

  • Endometrial hyperplasia: endometrial hyperplasia is of different types and is usually treated with medications that work like the hormone progesterone and/or surgery to remove the uterus.

  • Gyne-cancer: depending on the type of cancer and stage of cancer you may be advised surgery/ chemotherapy/ radiation.

  • Endometrial atrophy: are usually treated with medications that work like the oestrogen hormone. Oestrogen medicine can come as a tablet, vaginal gel or creams, skin patches, or a soft flexible ring that is put inside your vagina and slowly releases the medication. Please take these medications as prescribed by your doctor as long term use of these medications can cause endometrial cancer. 

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