Post menopausal bleeding — Obstetrics & Gynecology

POSTMENOPAUSAL VAGINAL BLEEDING

The most important take-home point is that it is not “normal” and you should see your doctor if you have this as soon as possible, even if the bleeding is light or temporary.

Definition

Any vaginal bleeding occurring in menopause, defined as 12 months of no menstrual bleeding (without another identified cause)

Common causes

A number of conditions can cause abnormal bleeding during the menopause. Women who take hormone therapy may experience cyclical bleeding. Any other bleeding that occurs during menopause is abnormal and should be investigated. Causes of abnormal bleeding during menopause include:

● Atrophy or excessive thinning of the tissue lining the vagina and uterus, caused by low estrogen levels

● Cancer or precancerous changes (hyperplasia) of the uterine lining (endometrium) [about 10% of all postmenopausal bleeding], or less commonly, of the uterine wall, cervix, vagina, or vulva

● Endometrial polyps

● Infection of the uterus

● Pelvic trauma

● Vaginal abrasions from a vaginal pessary for prolapse

● Use of blood thinners or anticoagulants

● Side effects of radiation therapy

● Bleeding from bladder or rectum, which can sometimes be difficult to distinguish from genital tract bleeding

Steps in evaluation of postmenopausal bleeding

Initial assessment — While taking a woman's medical history, a clinician will review the duration and amount of bleeding; factors that seem to bring the bleeding on; symptoms that occur along with the bleeding such as pain, fever, or vaginal odor; if bleeding occurs after sexual intercourse; whether there is a personal or family history of bleeding disorders; the woman's medical history and medications she is taking; recent weight changes, stress, a new exercise program, or underlying medical problems.

The clinician will perform a physical examination to evaluate the woman's overall health and a pelvic examination to confirm that the bleeding is from the uterus and not from another site (eg, the external genitals, urinary tract, or rectum). During the pelvic examination, the clinician will look for any obvious lesions (cuts, sores, or tumors) and will examine the size and shape of the uterus. He or she will examine the cervix to look for signs of cervical bleeding, and a Pap smear may be obtained to screen for cervical cancer (the cervix is at the lower end of the uterus, where it opens to the vagina).

Endometrial assessment — Tests that assess the endometrium (lining of the uterus) may be performed to rule out endometrial cancer and structural abnormalities such as uterine polyps. Such tests include:

Endometrial biopsy — An endometrial biopsy is often performed to rule out endometrial cancer or abnormal endometrial growths. Risk factors for cancer include obesity, history of irregular periods, history of tamoxifen use or a family history of endometrial or colon cancer. During the biopsy, a thin instrument is inserted through the vagina and cervix into the uterus to obtain a small sample of endometrial tissue. The biopsy (which often causes temporary uterine cramping) can be performed in a health care provider's office without anesthesia. Because only a small portion of the endometrium is sampled, the biopsy may miss some causes of bleeding and other tests are sometimes necessary.

Transvaginal ultrasound — An ultrasound uses sound waves to measure an organ's shape and structure. In a transvaginal ultrasound, an ultrasound probe is inserted into the vagina so that it is closer to the uterus and can provide a clear image of the uterus. The lining of the uterus is evaluated and measured; postmenopausal women normally have a thin endometrial lining; in postmenopausal women with uterine bleeding, if the lining is thicker than 4 or 5 mm, additional evaluation with a hysteroscopy may be appropriate. Ultrasound cannot distinguish between different types of abnormalities (eg, polyp versus cancer) and further testing may be necessary.

Hysteroscopy — During hysteroscopy, a small scope is inserted through the cervix and into the uterus. Air or fluid is injected to expand the uterus and to allow the physician to see the inside of the uterus. Tissue samples may be taken. Anesthesia is typically used to minimize discomfort during the procedure, and it is generally performed as a same-day surgery in an operating room.

Dilation and curettage (D&C) — In a D&C, the cervix or opening of the uterus is dilated and instruments are inserted and used to remove endometrial or uterine tissue. A D&C usually requires anesthesia, and often is performed together with hysteroscopy.

Treatment of postmenopausal bleeding

Treatment of postmenopausal bleeding will be determined by the cause of the bleeding.

● Atrophy or excessive thinning of the tissue lining the vagina and uterus, caused by low estrogen levels, can be treated with nonhormonal vaginal moisturizers/lubricants, or by low dose vaginal estrogen creams or tablets which help to improve thickness and elasticity and lubrication to the vaginal walls. These products are not the same as “hormone replacement therapy” as they are much lower dose, with minimal absorption, and are designed to be a local therapy in the genital tract when used in appropriate doses.

● Cancer of the uterine lining (endometrium) is most often treatable with a total hysterectomy (surgical removal of the uterus and cervix), and removal of both ovaries and tubes. In a small percentage of cases, further treatment such as chemotherapy or radiation may be recommended, but the vast majority of endometrial cancers are diagnosed at an early stage and cured with surgery.

● Cancer of the cervix may be treated with surgery or chemotherapy/radiation, depending on stage (how large the tumor is, and whether it has spread at all).

● Endometrial polyps are usually removed with hysteroscopy (see above), and sent for pathology to rule out cancer (the vast majority are benign, and no further treatment is needed after removal of these).

● Infection of the uterus is usually treatable with antibiotics.

● Vaginal abrasions from a vaginal pessary for prolapse typically resolve after leaving a pessary out for a few weeks to allow healing.

Adapted from: www.uptodate.com: Patient education: Abnormal uterine bleeding (Beyond the Basics) Author: Andrew M Kaunitz, MD. Topic last updated Jan. 2019.