Vaginal bleeding after the menopause is not normally expected and there may be a number of different causes of postmenopausal bleeding.
When a woman has gone through menopause, she normally does not expect to have any further bleeding. However, women may sometimes experience additional vaginal bleeding. If she has gone through menopause, doctors consider the bleeding abnormal, and a woman should contact her physician.
Examples of bleeding symptoms that could indicate that she needs to call her doctor include bleeding after sex or bleeding that is very heavy and more than "spotting." Most commonly, the bleeding is unrelated to an issue with menstruation and may be due to another cause that should be identified.
Postmenopausal bleeding can be due to a number of causes. Examples of some of the most common causes include:
- Endometrial atrophy: When the hormone estrogen stops being produced due to menopause, a woman's endometrial lining may start to become thinner. As a result, the lining of the endometrium may be more likely to bleed.
- Endometrial hyperplasia: This condition causes the uterine lining to become thicker instead of thinner, giving rise to heavy or irregular bleeding. The cause of this condition is most commonly excess estrogen without the hormone progesterone to offset it. Endometrial hyperplasia can sometimes lead to the development of endometrial cancer.
- Endometrial cancer: This is cancer of the endometrial lining. An estimated 10 percent of postmenopausal women with uterine bleeding experience the bleeding due to endometrial cancer.
- Polyps: Polyps are growths that can develop on the lining of the uterus. They are usually noncancerous but can cause unusual or heavy bleeding. Polyps can sometimes grow inside the cervical canal. When this occurs, a woman may experience bleeding when she has sex.
Other potential, but less likely, causes of postmenopausal bleeding include:
- clotting problems
- infection of the uterine lining, which is known as endometritis
- trauma to the pelvis
- bleeding from the urinary tract
- thyroid disorders
Hormone medications, such as tamoxifen, may also cause postmenopausal bleeding as a side effect. Many women will experience breakthrough bleeding as a result of taking hormone replacement therapy in the first 6 months.
Regardless of the potential underlying cause, it is important that a woman sees her doctor when she has vaginal bleeding.
A doctor will start an exam for postmenopausal bleeding by asking the woman about the symptoms she may be experiencing. A doctor will likely ask:
- when she first noticed her symptoms
- how much she bleeds
- if she has any family history of postmenopausal bleeding
Depending upon a woman's symptoms, a doctor may recommend one or more of a number of tests.
Examples of tests used to diagnose the cause of postmenopausal bleeding include:
- Dilation and curettage (D&C): This procedure involves dilating or widening the cervix to obtain a larger tissue sample. It also involves using a special tool called a hysteroscope to see inside the uterus to identify any potential growths.
- Endometrial biopsy: This procedure involves inserting a small, thin tube into the vagina to reach the cervix to take a sample of tissue lining from the uterus. This tissue can then be tested for the presence of abnormal cells, such as cancerous cells.
- Hysteroscopy: This procedure involves a doctor inserting a tool with a thin, lighted camera on the end to examine the inside of the uterus and its lining. The approach can help a doctor to identify polyps or abnormal growths.
- Sonohysterography: This procedure involves injecting fluid through the vagina and into the uterus. A doctor will then use an ultrasound machine - which uses sound waves to identify differences in tissues - to visualize the uterus. This is known as a transabdominal ultrasound. The process can allow a doctor to determine whether the uterine lining is thicker or thinner than expected.
- Transvaginal ultrasound: This procedure involves inserting a special ultrasound probe into the vagina to allow a doctor to visualize the uterus from the bottom of the uterus, instead of from the lower abdomen.
While most of these tests can be performed at a doctor's office, others, such as a D&C, are often performed at a hospital or surgery center.
The treatment that a doctor may decide upon will be based on the cause of the bleeding.
Treatments for postmenopausal bleeding often depend upon the underlying cause associated with the bleeding.
A doctor can consider the information gathered from the testing to work out the best course of treatment. Some examples of treatments for specific underlying causes include:
- Polyps: Treatment of polyps may include surgical removal of the polyps so that they can no longer bleed.
- Endometrial cancer: Often, the treatment for endometrial cancer is to remove the uterus as well as any nearby lymph nodes to which the cancer could have spread. This procedure is known as a hysterectomy. Depending upon the cancer's spread, a woman may also need to undergo chemotherapy and radiation treatments.
- Endometrial hyperplasia: Women who have this condition may take medications known as progestins, which can help to prevent the endometrial lining from becoming too thick. However, a doctor may recommend regular testing for cancerous cells inside the uterus to ensure that they do not have endometrial cancer.
If a woman has vaginal bleeding due to the thinning of endometrial tissues, a doctor may prescribe vaginal estrogen. This medication can reduce the effects of thinning tissues.
An estimated 4 to 11 percent of women of women experience vaginal bleeding after they go through menopause.
While women can expect to experience some irregular bleeding before they go through menopause - during a time period known as perimenopause - bleeding is not the norm afterward.
Although bleeding after menopause is not always cause for concern, a woman should always consult her doctor if she does have postmenopausal bleeding to rule out more serious causes, such as endometrial cancer.
Many postmenopausal bleeding diagnostic methods do not have to be invasive and can be done at a doctor's office.