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 years. However, the timing varies among women.  The years leading up to this point are called peri-menopause. This means “around menopause.”

Changes in hormone levels can affect ovulation and change bleeding patterns as a woman nears menopause. Your periods may become shorter or longer. Blood flow may get heavier or lighter. 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. Any bleeding after menopause should be checked by a doctor. 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, thyroid abnormality.

Hormone Therapy(HT)

Some women choose to take the hormones estrogen and progesterone after menopause to relieve hot flashes and vaginal dryness and to protect against osteoporosis. If a woman has had a hysterectomy then progesterone is not needed.

More than one half of women have bleeding or spotting after they start hormone therapy (HT). The pattern of the bleeding depends on how HT is taken. When you take estrogen and progesterone daily, the bleeding lessens within a few months.

A woman also is more likely to have bleeding with HT if it’s been less than three years since menopause when she starts the therapy. A woman on HT should be evaluated if:

She has been on HT for six months or more and still has bleeding

She has not been bleeding and suddenly begins to bleed again

Risks for Endometrial Cancer 

Obesity, pcos, family history of colon/breast/uterine or ovarian cancer, irregular menses

Diagnosis

To diagnose abnormal bleeding, your doctor will review your personal and family health history. 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. It is then 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 in the uterus.

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 is caused by hormonal changes or growths. The endometrium is thinning, estrogen may be given. If the endometrium is growing too much, progesterone may be used. It may take a few months for HT to control your bleeding.

If there are growths that are causing the bleeding, you may have to have surgery to remove them. This may be done with hysteroscopy with D&C. If you have endometrial hyperplasia, it may be treated with medication or surgery. If you have endometrial cancer, surgery is needed in most cases.

Finally . . .

If you have bleeding after menopause, see your doctor. The earlier the cause of postmenopausal bleeding is found, the better it can be treated. If bleeding comes back after treatment, your doctor needs to be notified.