Postmenopausal Bleeding
Menopause, the end of ovulation and menstrual periods, naturally occurs for most women at 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 that occur around the time of menopause.
Postmenopausal bleeding is not a normal condition. Because it can be a symptom of a serious medical condition, any episodes of postmenopausal bleeding should be brought to the attention of your doctor.
Women taking hormone replacement therapy (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.
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 or estrogen-secreting tumors in other parts of the body.
The most common cause of postmenopausal bleeding is HRT. About 5% to 10% of postmenopausal bleeding is due to endometrial cancer or its precursors.
For diagnosis:
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: 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. 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). The presence of liquid in the uterus helps make any structural abnormalities more distinct.
Treatment
It is common for women just beginning HRT to experience some bleeding and 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, the uterus, cervix, ovaries, and fallopian tubes may be removed depending on the type and location of the cancer. Postmenopausal bleeding that is not due to cancer and cannot be controlled by any other treatment usually requires a hysterectomy.
