09 Jun Postmenopausal Bleeding: What Does it Mean and What Should You Do?

Postmenopausal Bleeding: What Does it Mean and What Should You Do?

Postmenopausal bleeding can be of concern if you have stopped menstruating for a while. It might be frightening to see blood again after you have grown accustomed to not having your period. It is best to contact your local doctor immediately for an appointment so they can assess whether it might be an indication of an underlying health issue. Your local doctor may also refer you to see a gynaecologist.

6 Reasons You Might Have Postmenopausal Bleeding

Postmenopausal bleeding can indicate a number of things other than cancer. Here are the main causes below:

1. Vaginal and Endometrial Atrophy

Lower estrogen hormone levels can thin the uterine lining and vaginal tissue. This is known as vaginal atrophy and can present as postmenopausal bleeding. This is the commonest cause of postmenopausal bleeding.

2. Fibroids and Uterine Polyps

Fibroids are tumour growths from within the muscle of the uterus and are mostly benign. Cancerous fibroids are rare, usually quoted in 1 in 700, and usually present with postmenopausal bleeding and abdominal pain. Uterine polyps are growths from the inside lining of the uterus. Uterine polyps (also termed endometrial polyps) are common and mostly benign, it is important to remove them to rule out endometrial hyperplasia or cancer.

3. Endometrial Hyperplasia

Endometrial hyperplasia is a precancerous condition when the uterine wall becomes abnormally thick and causes excessive bleeding. Endometrial Hyperplasia is categorised as either simple or complex, with or without cellular atypia. Simple endometrial hyperplasia without atypia has 1 % risk of uterine cancer, while complex hyperplasia with atypia associates with up to 30% risk of uterine cancer. Up to 50% of complex atypical hyperplasia already have coexisting cancer at the time of diagnosis.

4. Endometrial Cancer or Uterine Cancer Can Cause Postmenopausal Bleeding

Risk factors for endometrial cancer include overweight and obesity, diabetes, high blood pressure, Polycystic Ovarian Syndrome (PCOS) amongst others. Family history of bowel, endometrial, breast or ovarian cancer, or Lynch syndrome also increases this risk. Endometrial cancer is the commonest gynaecological cancer and its incidence is rising, most likely due to the rising incidence of obesity. The risk of endometrial cancer doubles with every 5 BMI (body mass index) units above the normal range (20-25), such that a woman with a BMI of 35 has an 8-fold increased risk.

5. Cervical Cancer

Cervical cancer needs to be ruled out in women with postmenopausal bleeding. An internal examination with your doctor or gynaecologist is essential. Along with postmenopausal bleeding, cervical cancer may also present as vaginal bleeding between periods, longer or heavy menstruation, pain or bleeding during or after intercourse, pelvic pain, and a change in vaginal discharge. It is important to keep up with your 5 yearly cervical screening test (Pap test), even after menopause.

6. Hormone Therapy Can Lead to Postmenopausal Bleeding

Cyclical menopause hormone therapy (MHT) contains a combination of estrogen and progesterone, which can lead to period-like bleeding. You can expect this type of withdrawal bleeding, and should be at the end of or after the progesterone phase. You should, however, investigate any time deviation or excessively heavy bleeding occurs. 

What to Do After You Notice Postmenopausal Bleeding?

Instead of worrying about the worst-case scenario, schedule an appointment with your local doctor or gynaecologist. Examination, including internal speculum examination is essential. A number of tests can then ensue.

Transvaginal Ultrasonography

Your doctor will organise an assessment of your uterine cavity and endometrial thickness through a transvaginal ultrasound. A thin elongated handheld device called a transducer is inserted into the vagina to allow close examination of the pelvic organs, including the uterus and its internal lining. In a postmenopausal woman, the endometrium is normally thin and measures less than 4mm.

Endometrial Biopsy

To check for pre-cancerous or cancerous growth, your gynaecologist make take a sample of the endometrial lining and send it to the lab. Endometrial biopsy is commonly done through endometrial pipelle sampling in the clinic rooms, or through a hysteroscopy under general anaesthetic. The hysteroscopy also allows visualisation of the endometrium and removal of any other growth such as polyps if present.

Contact Your Gynaecologist For Assessment and Treatment of Postmenopausal Bleeding

Treatment depends on what your gynaecologist finds. Dr Kent Kuswanto is an expert in female reproductive health and can guide you through the process and help determine the best treatment plan for you.