Postmenopausal bleeding should always be investigated.
The menopause is when you have not had a period for 12 months.
Postmenopausal bleeding is any bleeding after the menopause, no matter how light.
Even a brown discharge is postmenopausal bleeding.
Postmenopausal bleeding usually occurs because of thinning of the lining of the womb or vagina.
Postmenopausal bleeding may be an early indication of a cancer of the womb.
Simple, one stop investigation, should find the cause of the problem.
Causes of postmenopausal bleeding
Atrophic vaginitis is when the skin of the vagina gets very thin because of a lack of estrogen.
This is the most common cause of postmenopausal bleeding.
Before the menopause, estrogen from the ovaries keeps the skin of the vagina healthy.
After the menopause, the estrogen levels drop and the skin of the vagina thins. This allows it to get damaged more easily, and sometimes it becomes inflamed. This process also occurs inside the womb, and bleeding can occur from either the womb or the vagina.
The site of the bleeding is often not found. We make this diagnosis by excluding all other possibilities.
Uterine polyps occur when the lining of the uterus or womb thickens locally. The peristaltic action of the uterus pulls on the thickened area. This action pulls it up into a little polyp, or out pouching of the skin. Polyps are of varying size, but usually are benign. When found after the menopause, endometrial hyperplasia may be the cause.
Endometrial hyperplasia is when the lining of the uterus is growing faster than it should do. These cells are not under normal control. Simple hyperplasia is a benign condition, with a very low risk of becoming a cancer. If the cells are more abnormal, we call the changes atypical hyperplasia. These changes have a significant risk of becoming a cancer.
Benign ovarian cysts can release estrogen that can cause postmenopausal bleeding. We detect these cysts using a pelvic ultrasound scan. Read more on ovarian cysts.
Uterine cancer is the most common cancer found in women with postmenopausal bleeding. We may find this after one episode of bleeding. This usually causes repeated bleeding. Most endometrial cancers present at an early stage because they cause postmenopausal bleeding. We treat endometrial cancer by a hysterectomy. Often a keyhole procedure will be appropriate. Surgery is usually all that is necessary to cure endometrial cancer.
Cancer of the Cervix
Cancer of the cervix can cause postmenopausal bleeding. Cancer of the cervix is very uncommon in women who have had regular smears. We diagnose cancers of the cervix early in our community. The cure rate for early cancer of the cervix is very good.
Cancer of the Ovary
Some ovarian cancer can present with postmenopausal bleeding. Ovarian cancers can produce estrogen which destabilises the thin postmenopausal endometrium. For early stage ovarian cancer the cure rate is very good. Many ovarian cancers present at stage III and are more difficult to cure
Treatment for Postmenopausal Bleeding
Usually postmenopausal bleeding occurs only once or twice and doesn’t recur. With recurrent bleeding from this cause, we prescribe topical estrogen. Usually no treatment is necessary.
An expert ultrasound scan will check for many causes of postmenopausal bleeding
This is the first step in finding the cause of the bleeding
What will happen during your clinic visit?
We usually arrange a pelvic ultrasound at the start of your first clinic. This looks carefully at the inside of the uterus. An ultrasound scan can visualise uterine polyps or endometrial hyperplasia. The ultrasound also examines the ovaries for cysts or early ovarian cancers.
Measuring the thickness of the endometrium on ultrasound and is important. If the lining of the uterus is less than 5 mm, then the chances of an endometrial cancer is very low. In this case a biopsy of endometrium is not necessary. If the lining is over 5mm, then we would usually arrange a biopsy from the lining of the womb. We normally do a pelvic examination.
We can see if there is an abnormality of the cervix or vagina. We sometimes take a smear test at the same time. If a discharge is present, we take swabs from the vagina to check for infections.
If we need a more detailed assessment of the cervix, we can examine the cervix with colposcopy.
We can take a biopsy of the endometrium in several ways:
We do a Pipelle biopsy in the clinic. We introduce a fine tube 3 mm in diameter into the cavity of the womb. Using the plunger in the device to produce a high suction, we draw tissue into the central part of the device. The disadvantage is that it can be uncomfortable or even painful. It is over 90% reliable at diagnosing cancers. It may fail to get an adequate tissue sample, particularly if the abnormality is focal. Also, it may not be possible to insert the device
We do outpatient hysteroscopy without anaesthetic or with sedation. For some women the procedure may be relatively painless. Many women find the procedure very uncomfortable. It is difficult to anaesthetise the inside of the uterus. We take a biopsy during the procedure with a Pipelle as above.
Daycase hysteroscopy and D & C
This is the gold standard technique. We perform the procedure under a very light general anaesthetic. We can take a very good sample of the endometrium, and this provides the best diagnostic success rate.