Menopausal Bleeding

Bleeding Around and After Menopause

Menopause is the time in a woman’s life when she stops having menstrual periods. It occurs in most women around age 52, but the timing varies among women. The years leading up to this point are called peri-menopause, which means “around menopause.” Changes in hormone levels can affect ovulation and bleeding patterns as a woman nears menopause. Your periods may become shorter or longer, blood flow may get heavier or lighter, or you may begin to skip periods. When a woman has not had a period for one year, she is postmenopausal.

Causes of Abnormal Bleeding

Although periods tend to be less regular around menopause, irregular bleeding can be a sign of problems. A doctor should check for any bleeding after menopause. You also should be checked if you are older than 55 years and still have menstrual periods.

In postmenopausal women, bleeding is most often caused by:

• A thinning of the uterine lining (endometrial atrophy)
• Hormone therapy
• Polyps (growths that are usually benign but tend to bleed on their own, like colon polyps)
• Endometrial hyperplasia (a precancerous lesion of the uterine lining).
• Endometrial cancer (cancer of the lining of the uterus)

In postmenopausal women with uterine bleeding, one in eight will receive a diagnosis of endometrial cancer.  Bleeding can be an early sign of this type of cancer. When this type of cancer is found early, it often can be treated with success.

Other causes of bleeding in menopausal women include genitourinary syndrome of menopause ( dry, friable vaginal/vulvar tissue), vaginal or cervical growth, skin condition, medications, and thyroid abnormality.

Hormone Therapy(HT)

For many women experiencing menopausal symptoms like hot flashes and vaginal dryness, hormone therapy (HT) can offer relief. Typically, this involves taking estrogen and progesterone, unless a woman has had a hysterectomy, in which case progesterone isn’t necessary. However, it’s common for over half of women on HT to experience bleeding or spotting initially, with the pattern depending on the regimen. With daily estrogen and progesterone intake, this bleeding often diminishes within a few months.

Bleeding is more likely if a woman begins HT within three years of menopause. It’s important for women on HT to be monitored, especially if they experience bleeding. Evaluation is recommended if bleeding persists after six months of HT use or if bleeding suddenly occurs after a period of absence. Monitoring and addressing any irregular bleeding are crucial aspects of managing hormone therapy effectively.

Risks for Endometrial Cancer

Obesity, Polycystic ovary syndrome (PCOS) , family history of colon/breast/uterine or ovarian cancer, and irregular menses.

Diagnosis

Your doctor will review your personal and family health history to diagnose abnormal bleeding. You will have a physical exam and may have blood tests. Other tests may be needed based on your symptoms:

Endometrial biopsy: Using a catheter (tube), a small amount of tissue is gently scraped from the lining of the uterus and looked at under a microscope.

Ultrasonography:  Sound waves are used to create a picture of the pelvic organs. The device may be placed on the abdomen or in the vagina.

Sonohysterography: A small amount of fluid is injected into the uterus, and sound waves are used to create a picture of the pelvic organs to detect abnormal changes.

Hysteroscopy: A thin device is inserted through the vagina and cervix to view the inside of the uterus and to sample the tissue. The tissue is then sent to a pathologist for a diagnosis. This is a very low-risk outpatient surgery.

Treatment

Postmenopausal bleeding can be caused by hormonal changes or abnormal growths in the uterus. When the endometrium thins due to hormonal changes, estrogen therapy may be prescribed to help. Conversely, if there’s excessive growth of the endometrium, progesterone might be used to counteract it. It’s important to note that controlling bleeding with hormone therapy may take several months to achieve desired results. However, if growths are responsible for the bleeding, surgical intervention may be necessary to remove them. Procedures like hysteroscopy with dilation and curettage (D&C) might be performed for this purpose. If the cause of bleeding is endometrial hyperplasia, it can be managed with medication or surgery depending on the severity. In cases of endometrial cancer, surgery is typically the primary treatment option. Effective management of postmenopausal bleeding involves identifying the underlying cause and tailoring treatment accordingly, whether it be hormonal therapy or surgical intervention.