Postmenopausal Bleeding: Causes, Risks, and Treatment Options

In short: Any vaginal bleeding more than 12 months after the last period means seeing the doctor and must not be ignored. Most causes are minor, such as thinning of the vaginal tissue or uterine lining, benign polyps or a thickened lining, especially with hormone treatment, but cancer must be ruled out, particularly with obesity, diabetes, high blood pressure or no children. Treatment depends on the cause.

Menopause is the point at which your menstrual cycle stops for good — officially confirmed after 12 months without a period. It usually happens in women in their 40s and 50s.

In the years leading up to menopause, periods can become irregular or heavier than usual. This transition, known as perimenopause, usually lasts about 4 years but can last longer in some women.

Any vaginal bleeding, spotting, or period-like blood loss that happens after menopause is called postmenopausal bleeding (PMB).

Bleeding after menopause is often caused by a minor, treatable condition, but it can occasionally be an early sign of something more serious. That’s why doctors recommend it always be checked promptly and treated as a possible warning sign of cancer until proven otherwise.

The reassuring news is that when detected early, most conditions — including cancers — can usually be treated successfully.

Causes of Postmenopausal Bleeding

Most of the time, postmenopausal bleeding is caused by:

• Inflammation and thinning of the vaginal tissue (called atrophic vaginitis)
• Thinning of the endometrium.
• Benign polyps in the cervix or the uterus.
• [Overgrowth of the uterine lining (endometrial hyperplasia), which is linked to excess estrogen that is not balanced by progesterone — for example with obesity or estrogen-only HRT in a woman who still has her uterus
• In about 1 in 10 cases, post-menopausal bleeding is caused by cancer, most often cancer of the uterine lining (endometrium) and less often of the cervix.
• Risk Factors of endometrial cancer

It’s important to be aware of the factors that can put some women at higher risk of endometrial cancer, one of the more serious causes of postmenopausal bleeding:

• Diabetic patients
• Hypertension
• Null parity, having no children
• History of Polycystic ovary syndrome
• Obesity
• Taking unopposed estrogen hormone replacement therapy
• Receiving Tamoxifen as a treatment for breast cancer
• Family history of gastrointestinal and genitourinary cancers like ovarian and endometrial cancers and colon cancer especially at young ages
• Usually in women above 60 years of age

• Management of Postmenopausal Bleeding

If you experience postmenopausal bleeding, a thorough history, examination, and investigations are essential.

The first step is usually a referral to a gynecologist, who will review:

• History about any medical problems like diabetes, hypertension, polycystic ovaries, thrombosis renal diseases, endocrine or cardiac diseases.
• History of cancers in family and patient.
• History of marriage, sexual life, pregnancies and deliveries.
• History of taking any medications like anticoagulants or hormones.
• Examination of vital signs, breast masses, abdominal masses, cervical or vaginal masses or abnormalities through an internal examination using speculum.
• Investigations: a vaginal ultrasound scan to measure the thickness of the uterine lining; if the lining is 4 mm or thicker, the bleeding recurs, or you are at high risk, a sample of the lining is taken (endometrial biopsy, often with hysteroscopy). The cervix is examined and a cervical screening test is done if it is due or the cervix looks abnormal, and a blood count if bleeding is heavy.

You can read how this procedure is carried out in our guide to hysteroscopy.

Treatment Options for Postmenopausal Bleeding

The right treatment depends on what’s causing the bleeding.

• Thinning of the vaginal tissue is treated with low-dose vaginal estrogen (cream, tablet or ring) or non-hormonal vaginal moisturisers and lubricants. Estrogen tablets must never be taken alone by a woman who still has her uterus, as this increases the risk of endometrial cancer.

• Polyps are removed under direct vision with a hysteroscope, often as an outpatient procedure with local anaesthesia or sedation, or under general anaesthesia if needed, and sent for examination

• A thickened endometrium must first be sampled — by an outpatient endometrial biopsy or by hysteroscopy with biopsy — and the tissue sent for histopathology to find the cause before treatment is chosen.

• For endometrial hyperplasia without atypia, treatment is usually a hormonal IUD (Mirena) or progestogen tablets, with repeat biopsies to confirm it has resolved. Hyperplasia with atypia (abnormal cells) carries a higher risk of cancer and is usually treated by hysterectomy.

This finding has its own article, where we explain a thickened endometrium in more detail.

[* Total hysterectomy (removing the uterus and cervix, usually with the tubes and ovaries after menopause) is the definitive treatment when needed; a subtotal hysterectomy is not suitable when hyperplasia or cancer is present.

If you or a loved one is experiencing bleeding after menopause, don’t wait —

How this screening test works is covered in our article on cervical cancer screening and prevention.

Dr. Najeeb Layyous and his team are here to provide a careful evaluation and guide you toward the right treatment plan.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist