Postmenopausal Bleeding

Definition

Postmenopausal bleeding is bleeding from the reproductive system that occurs six months or more after menstrual periods have stopped due to menopause.

Description

Menopause, the end of ovulation and menstrual periods, naturally occurs for most women age 40-55 years. The process of ending ovulation and menstruation is gradual, spanning one to two years.

Postmenopausal bleeding is bleeding that occurs after menopause has been established for at least six months. It is different from infrequent, irregular periods (oligomenorrhea ) that occur around the time of menopause.

Many women experience some postmenopausal bleeding. However, postmenopausal bleeding is not normal. Because it can be a symptom of a serious medical condition, any episodes of postmenopausal bleeding should be brought to the attention of a woman's doctor.

Women taking estrogen (called hormone replacement therapy or HRT) are more likely to experience postmenopausal bleeding. So are obese women, because fat cells transform male hormones (androgens) secreted by the adrenal gland into estrogen.

Causes and symptoms

Postmenopausal bleeding can originate in different parts of the reproductive system. Bleeding from the vagina may occur because when estrogen secretion stops, the vagina dries out and can diminish (atrophy). This is the most common cause of bleeding from the lower reproductive tract.

Lesions and cracks on the vulva may also bleed. Sometimes bleeding occurs after intercourse. Bleeding can occur with or without an associated infection.

Bleeding from the upper reproductive system can be caused by:

• hormone replacements
• endometrial cancer
• endometrial polyps
• cervical cancer
• cervical lesions
• uterine tumors
• ovarian cancer
• estrogen-secreting tumors in other parts of the body

The most common cause of postmenopausal bleeding is HRT. The estrogen in the replacement therapy eases the symptoms of menopause (like hot flashes), and decreases the risk of osteoporosis. Sometimes this supplemental estrogen stimulates the uterine lining to grow. When the lining is shed, post-menopausal bleeding occurs. Most women on HRT usually take the hormone progesterone with the estrogen, and may have monthly withdrawal bleeding. This is a normal side effect.

About 5-10% of postmenopausal bleeding is due to endometrial cancer or its precursors. Uterine hyperplasia, the abnormal growth of uterine cells, can be a precursor to cancer.

Diagnosis

Diagnosis of postmenopausal bleeding begins with the patient. The doctor will ask for a detailed history of how long postmenopausal bleeding has occurred. A woman can assist the doctor by keeping a record of the time, frequency, length, and quantity of bleeding. She should also tell the doctor about any medications she is taking, especially any estrogens or steroids.

After taking the woman's history, the doctor does a pelvic examination and Pap test. The doctor will examine the vulva and vagina for signs of atrophy, and will feel for any sign of uterine polyps. Depending on the results of this examination, the doctor may want to do more extensive testing.

Invasive diagnostic procedures

Endometrial biopsy allows the doctor to sample small areas of the uterine lining, while cervical biopsy allows the cervix to be sampled. Tissues are then examined for any abnormalities. This is a simple office procedure.

Dilatation and curettage (D & C) is often necessary for definitive diagnosis. This is done under either general or local anesthesia. After examining the tissues collected by an endometrial biopsy or D & C, the doctor may order additional tests to determine if an estrogen-secreting tumor is present on the ovaries or in another part of the body.

Non-invasive diagnostic procedures

With concerns about the rising cost of health care, vaginal probe ultrasound is increasingly being used more than endometrial biopsy to evaluate women with postmenopausal bleeding. Vaginal ultrasound measures the thickness of the endometrium. When the endometrial stripe is less than 0.2 in (5 mm) thick, the chance of cancer is less than 1%. The disadvantage of vaginal ultrasound is that it often does not show polyps and fibroids in the uterus.

A refinement of vaginal probe ultrasound is saline infusion sonography (SIS). A salt water (saline) solution is injected into the uterus with a small tube (catheter) before the vaginal probe is inserted. The presence of liquid in the uterus helps make any structural abnormalities more distinct. These two non-invasive procedures cause less discomfort than endometrial biopsies and D & Cs, but D & C still remains the definitive test for diagnosing uterine cancer.

Treatment

It is common for women just beginning HRT to experience some bleeding. Most women who are on HRT also take progesterone with the estrogen and may have monthly withdrawal bleeding. Again, this is a normal side effect that usually does not require treatment.

Postmenopausal bleeding due to bleeding of the vagina or vulva can be treated with local application of estrogen or HRT.

When diagnosis indicates cancer, some form of surgery is required. The uterus, cervix, ovaries, and fallopian tubes may all be removed depending on the type and location of the cancer. If the problem is estrogen- or androgen-producing tumors elsewhere in the body, these must also be surgically removed. Postmenopausal bleeding that is not due to cancer and cannot be controlled by any other treatment usually requires a hysterectomy.

Prognosis

Response to treatment for postmenopausal bleeding is highly individual and is not easy to predict. The outcome depends largely on the reason for the bleeding. Many women are successfully treated with hormones. As a last resort, hysterectomy removes the source of the problem by removing the uterus. However, this operation is not without risk and the possibility of complications. The prognosis for women who have various kinds of reproductive cancer varies with the type of cancer and the stage at which the cancer is diagnosed.

Prevention

Postmenopausal bleeding is not a preventable disorder. However, maintaining a healthy weight will decrease the chances of it occurring.

Resources

ORGANIZATIONS

American Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA 30329-4251. (800) 227-2345. 〈http://www.cancer.org〉.

National Cancer Institute. Building 31, Room 10A31, 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 422-6237. 〈http://www.nci.nih.gov〉.

KEY TERMS

Dilation and curettage (D & C)— A procedure performed under anesthesia during which the cervix is opened more (or dilated) and tissue lining the uterus is scraped out with a metal, spoon-shaped instrument or a suction tube. The procedure can be used to diagnose a problem or to remove growths (polyps).

Endometrial biopsy— The removal of uterine tissue samples either by suction or scraping; the cervix is not dilated. The procedure has a lower rate of diagnostic accuracy than D & C, but can be done as an office procedure under local anesthesia.

Endometrium— The tissue lining the inside of the uterus.

Fibroid tumors— Non-cancerous (benign) growths in the uterus. These growths occur in 30-40% of women over age 40, and do not need to be removed unless they are causing symptoms that interfere with a woman's normal activities.

Osteoporosis— The excessive loss of calcium from the bones, causing the bones to become fragile and break easily. Postmenopausal women are especially vulnerable to this condition because estrogen, a hormone that protects bones against calcium loss, decreases drastically after menopause.