Postmenopausal bleeding refers to any bleeding in a woman who has gone through menopause. Menopause is defined by the absence of menstrual bleeding for 12 months following a final period. Approximately 5 percent of office visits to the gynecologist are for the evaluation of postmenopausal bleeding.
Bleeding in a menopausal woman may arise from the uterus, cervix, vagina, or vulva, or from non-genital sites such as the urethra or rectum. The most common causes include atrophy(thinning of the lining of the uterus or the vagina due to low estrogen levels), endometrial(intrauterine) polyps, and uterine cancer or uterine hyperplasia(thickening of the uterine lining). It is important to note that 95% of cases of postmenopausal bleeding arise from benign causes. However, since the incidence of uterine cancer increases with age, it is a more common diagnosis in older women with bleeding. Endometrial adenocarcinoma is the most common genital cancer in women over age 45, thus much of the diagnostic evaluation will be directed towards ruling out this malignancy.
When visiting their gynecologist, women who present with postmenopausal bleeding will be asked questions about the onset and duration of bleeding, the possibility of trauma or association with sexual activity, and the presence of other symptoms and signs such as fever, pain, and change in urinary or bowel habits. In addition, they should be prepared to report all medications recently taken, especially hormones and blood thinners.
A thorough physical examination will be carried out, to examine the vulva, vagina, and cervix for lesions or atrophy, and to determine the shape and contour of the uterus and ovaries. A pap smear will be performed, if not up to date. If an obvious source of bleeding other than the uterus is not determined, then further evaluation of the uterine cavity is warranted. This may include an endometrial biopsy, to obtain a tissue sample from the uterine lining, a transvaginal ultrasound, or both. If either test is non-diagnostic, raises the suspicion of malignancy, or if there is persistent bleeding in spite of a negative in-office evaluation , an outpatient surgical procedure called hysteroscopy, which directly visualizes the uterine cavity, may be performed in conjunction with a D&C.
The treatment of postmenopausal bleeding will depend upon the final diagnosis, and includes treatment of genital atrophy, removal of polyps, and further surgery, such as hysterectomy if a malignancy is confirmed. Luckily, the prognosis for endometrial carcinoma is excellent if found at an early stage, therefore do not delay a visit to the office if you should experience any bleeding after menopause.
Ingrid A. Prosser, M.D., F.A.C.O.G.