Postmenopausal Bleeding: When Are Symptoms Concerning?
Bleeding sometimes, but not always, suggests endometrial cancer
Medically reviewed by Renita White, MD
Postmenopausal bleeding is bleeding from the vagina that occurs after menopause. Menopause is when a person who menstruates has not had a menstrual period for an entire year. It typically occurs between ages 45 and 55.
While postmenopausal bleeding often stems from benign (noncancerous) conditions, it can be the first sign of endometrial (uterine) cancer. As such, vaginal bleeding after menopause requires prompt medical attention from a healthcare provider.
This article reviews the symptoms, causes, and treatment of postmenopausal bleeding. Medications linked to postmenopausal bleeding and risk factors for endometrial cancer are also discussed.
Liudmila Chernetska / Getty Images
Symptoms of Postmenopausal Bleeding
Vaginal bleeding after menopause can manifest in different ways. Any type warrants a medical evaluation.
Postmenopausal bleeding may involve:
A streak or drop of blood on underwear or toilet paper
Bleeding that is similar to menstrual periods before menopause
Heavy bleeding with or without blood clots
Bleeding that occurs after sex
Pink, gray, or brown vaginal discharge
Accompanying Symptoms
Other symptoms may also be present depending on the cause of the postmenopausal bleeding. These include:
Fever
Dizziness
Fatigue
Pale skin
Low back pain
Constipation
Urinary problems (e.g., frequent urination or feeling the urge to urinate despite an empty bladder)
Causes of Bleeding After Menopause
There are numerous possible causes of bleeding after menopause.
Common causes include:
Polyps are outgrowths of the inner lining of the uterus. They are usually benign; however, in postmenopausal people, there is a higher risk for cancerous uterine polyps compared to premenopausal people. Less commonly, polyps may form in the cervix and, very rarely, in the vagina.
Atrophy is excessive thinning of the tissue covering the vagina and/or uterus. This thinning develops as a result of menopause-related estrogen deficiency. Besides vaginal discharge or spotting, people with atrophy can experience vaginal dryness and pain with sex.
Fibroids are overgrowths of the uterine muscle and usually decrease in size after menopause. They typically only cause postmenopausal bleeding in people on hormone replacement therapy. Other possible symptoms include pelvic pressure, constipation, and low back pain.
The most serious cause of postmenopausal bleeding is endometrial cancer, the fourth most common cancer in females in the United States.
With endometrial cancer, cells within the inner lining of the uterus grow abnormally and uncontrollably.
Symptoms of Endometrial Cancer
Vaginal bleeding occurs in around 90% of people with endometrial cancer, although non-bloody vaginal discharge can also be a sign. Symptoms like pelvic pain, feeling a pelvic mass, or unintentional weight loss typically indicate a more advanced cancer.
Other possible causes of postmenopausal bleeding include:
Endometrial hyperplasia: Thickening of the uterine lining that may or may not be associated with abnormal, precancerous cells
Endometritis: Infection of the uterus
Cervicitis Infection of the cervix
Other types of cancer, namely cervical cancer or ovarian cancer
Causes unrelated to the reproductive tract, such as a urinary tract infection or diverticulitis (intestinal infection)
Certain medications (see below)
What Medications Are Linked to Postmenopausal Bleeding?
Combined hormone replacement therapy (HRT), which involves taking two hormones, estrogen and progestin, is linked to postmenopausal bleeding.
Estrogen is the hormone that eases the symptoms of menopause, especially hot flashes or vaginal dryness.
Progestin (a hormone similar to progesterone) is needed to prevent endometrial cancer in people with a uterus. Without progestin, estrogen can lead to uterine tissue overgrowth.
Keep in mind that factors like estrogen dose and whether the progestin is taken cyclically or continuously affects the timing and nature of anticipated bleeding. So, if you are taking HRT, talk with your healthcare provider about what to expect regarding bleeding and when to call or follow up.
While not an exhaustive list, other medications associated with postmenopausal bleeding include:
Blood thinners like Jantoven (warfarin)
Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil or Motrin (ibuprofen)
Selective serotonin reuptake inhibitors, or SSRIs (rare)
Certain herbal supplements like ginseng
How to Diagnose What’s Causing Postmenopausal Bleeding
Finding out why a person may be experiencing postmenopausal bleeding requires a medical history, pelvic examination, and uterine evaluation.
Medical History
The diagnosis of postmenopausal bleeding starts with a thorough medical history by an obstetrician-gynecologist, or ob-gyn (a healthcare provider specializing in treating the female reproductive system).
During the appointment, a provider may ask some of these questions:
When did you go through menopause?
When did the bleeding begin?
How much bleeding is there? (e.g., soaking through a pad or a single drop of blood)
Does the bleeding occur after sex?
Are there any other symptoms present? (e.g., pelvic pain, abnormal urinary/bowel symptoms, or vaginal discharge)
The person will also be asked what medications they are taking, including any over-the-counter (OTC) drugs or herbal supplements, and whether they have a family history of cancer.
Pelvic Examination and Pap Smear
After a medical history, a healthcare provider will perform a physical examination, including a pelvic exam, to help pinpoint the bleeding site and look for suspicious growths or signs of infection.
A Pap smear will also be performed to check for cervical cancer. This procedure is necessary because it can be challenging to distinguish uterine from cervical bleeding since the cervix is the organ linking the vagina to the uterus.
Uterine Evaluation
In all cases of postmenopausal bleeding, it's crucial to evaluate the uterus.
A transvaginal ultrasound allows a healthcare provider to visualize the uterus and look for signs of possible endometrial cancer, like a mass or thickening of the inner uterine lining. It can also be used to look for polyps.
A small, lubricated device called a transducer will be placed through the cervix into the uterus during the ultrasound. The transducer produces sound waves that bounce off the uterus. A computer then translates the returning sound waves (echoes) as images.
Endometrial biopsy is the most commonly used test to diagnose endometrial cancer and can be performed in a gynecologist's office.
During the biopsy, the provider places a thin, lighted tube through the cervix into the uterus. The tube has a suction device on it that allows a small amount of uterine tissue to be removed.
The uterine tissue sample is then examined under a microscope by a healthcare provider called a pathologist for cancer cells.
Is an Endometrial Biopsy Painful?
Cramping is felt during the tissue removal, but it typically lasts a minute or less. In some cases, the healthcare provider injects a numbing medication into the cervix before the procedure to minimize any discomfort.
Related: What to Know Before an Endometrial Biopsy
In some cases, a hysteroscopy with dilation and curettage (D&C) is performed. Perhaps insufficient tissue is obtained during an endometrial biopsy, or the results are unclear.
During a hysteroscopy with D&C, the ob-gyn places a thin, lighted telescope (hysteroscope) into the vagina, through the cervix, and into the uterus.
Another thin instrument (curette) is used to scrape away tissue from the inner lining of the uterus. The tissue is then sent to a pathology lab for examination.
Complications and Risk Factors
Vaginal bleeding after menopause is never considered normal. Failing to get it checked out may result in worsening symptoms and serious complications like anemia or a cancer that has progressed.
Factors that increase the risk for endometrial cancer include:
Early menarche (first menstrual cycle)
Late menopause
Unopposed estrogen therapy (not taking progestin with estrogen if a person has a uterus)
Use of tamoxifen (a hormone therapy drug used to treat breast cancer)
Increasing age
Specific health problems, namely obesity, metabolic syndrome, diabetes mellitus, and polycystic ovary syndrome (PCOS)
Certain hereditary conditions, namely Lynch syndrome and Cowden syndrome
Bleeding at Home
Immediately call or see a healthcare provider if you experience any postmenopausal bleeding. Use pads (as you did when you were menstruating) until you see your provider.
Go to your nearest emergency room if you are experiencing heavy bleeding (soaking through a pad in one hour) and/or symptoms like severe dizziness or abdominal/pelvic pain.
Treatment to Stop Postmenopausal Bleeding
The treatment of postmenopausal bleeding depends on the underlying cause. For example, surgery may be needed to remove noncancerous growths, such as fibroids or polyps.
Likewise, vaginal estrogen therapy (available as cream, ring, or tablet) can often resolve postmenopausal bleeding due to thinning of the uterine and vaginal tissue (atrophy).
Treating endometrial cancer most often requires an operation called a total hysterectomy bilateral salpingo-oophorectomy). With this surgery, the uterus, fallopian tubes, and ovaries are removed.
Other treatments may be considered depending on the endometrial cancer stage (how far the cancer has spread), such as radiation and/or chemotherapy. For advanced endometrial cancer, immunotherapy may be used.
Learn More: How Endometrial Cancer Is Treated
Summary
Vaginal bleeding after menopause is not normal and necessitates urgent medical evaluation by an obstetrician-gynecologist. Symptoms of postmenopausal bleeding may range from spotting to heavy flow. Vaginal discharge or accompanying symptoms like pelvic pressure may also occur.
The good news is that in most cases, postmenopausal bleeding is due to benign growths or hormone-related thinning of the uterine/vaginal tissue. That said, serious causes, especially endometrial cancer, need to be thoroughly evaluated with diagnostic tests, such as a transvaginal ultrasound and endometrial biopsy.
Read the original article on Verywell Health.
