We all agree that menopause is a challenging time, often associated with a variety of emotional changes and physical symptoms, but most women think that the best part of menopause is an absence of periods. But what do you do if you see bleeding again? Let’s talk about postmenopausal bleeding…

Definition of post-menopausal bleeding (PMB)

Post-menopausal bleeding is any bleeding from the genital tract after menopause. The word menopause comes from the Greek words “menos” (meaning month) and “pause” (meaning cease). It literally translates as the last or final menstrual period in a woman’s life, but how do you know it is the last period? As for a lot of things in life, it is retrospective knowledge: once you don’t have a period for 12 months, you reach menopause and in fact become a post-menopausal woman. Any bleeding after this time is considered to be abnormal and requires investigation.

How common is post-menopausal bleeding?

Yes, 5 % of our gynecological reviews are for postmenopausal bleeding. Broader research suggests that it occurs in 4 – 11% of post-menopausal women. The good news is the likelihood of bleeding decreases over time, so something positive about getting older!

Causes of post-menopausal bleeding

There are numerous reasons, and the majority are benign (non-cancerous). However, you should always see your GP to investigate the possible underlying cause, and rule out pre-cancerous or cancerous causes.

Cervical and endometrial polyps

Polyps are localised overgrowths of the tissue lining the uterus (endometrial polyps) or the cervix (cervical polyps).

Cervical polyps are almost always benign, and are usually diagnosed during speculum examination; they can cause spotting, excessive discharge, and bleeding after sex. Cervical polyps can sometimes be removed during a speculum examination, by your gynaecologist twisting them off their stalk with an instrument called polyp forceps. This is not painful: usually women experience only some light pelvic cramping and vaginal spotting during and after this procedure. Larger polyps on a broad stalk may require removal under general anesthetic, in an operating theatre.

Endometrial polyps are localised overgrowths of the uterine lining (called the endometrium). Usually suspected on ultrasound, 95% of endometrial polyps are benign (non-cancerous). 5% of cases are pre-cancerous or frank endometrial cancer. The definitive diagnosis and treatment of endometrial polyps is hysteroscopy and polypectomy. This is minor surgery, performed under general anesthetic: a 5mm-wide video camera is placed through the vagina and cervix, into the uterine cavity to visualise the polyp and remove it under vision.

Cervical or endometrial polyps which have been removed will be always sent to the laboratory for analysis under the microscope by the pathology doctor.

Atrophy

During menopause, estrogen levels fall, and commonly cause thinning of endometrium (uterine lining), vagina, and vulva. When tissue becomes thin, it is more friable, and blood vessels are more superficial. Hence, atrophy increases the risk of bleeding. In addition, women with vulvo-vaginal atrophy  may experience vaginal dryness, and discomfort with sex.

Atrophy is diagnosed by your clinician performing a speculum examination: they will see atrophic changes of the vaginal lining.

Treatment is usually vaginal moisturisers and lubricants (with intercourse) and / or vaginal estrogen.

Vaginal moisturisers are intended for use routinely 2 – 3 times per week. There are multiple options on the market; the key ingredient is hyaluronic acid. They work by sticking to the vaginal lining and promoting hydration, stimulating lubrication, and improving elasticity.

On the other hand, lubricants are used at the time of intercourse, and have an immediate action allowing temporary relief of vaginal dryness and pain during sex.

Vaginal estrogens are most effective in treating vulvo-vaginal atrophy: they come in the form of cream or pessaries, and need a prescription.

Even though endometrial or vaginal atrophy is the most common cause for post-menopausal bleeding, more sinister causes such as endometrial hyperplasia and endometrial cancer must be ruled out.

Endometrial hyperplasia

Endometrial hyperplasia accounts for about 15% of post-menopausal bleeding. It is a condition when the lining of the uterus becomes thick, due to increased cell production. There are two types of hyperplasia: without and ‘with so-called ‘atypia.

If diagnosed after menopause, your gynaecologist will probably suggest that you have a hysterectomy. Removing the uterus removes the chance of these pre-cancerous changes progressing to actual uterine cancer.

For more information about endometrial hyperplasia, please read our previous blog post about it, here.

Endometrial cancer

Endometrial cancer is a fifth-commonest cancer in women. It is often diagnosed early, as it tends to cause abnormal bleeding (such as post-menopausal bleeding), which should prompt women to see their GP and have a pelvic ultrasound. In general, early diagnosis is associated with a good prognosis.

Medications

Some medications can contribute to post-menopausal bleeding, as outlined below.

Menopausal hormone therapy (MHT)

Break-through bleeding is common when MHT is initiated; any bleeding after 6 months of MHT use requires investigation.

Anti-coagulants or ‘blood thinners’

Anti-clotting medications such as warfarin, apixaban, dabigatran, and heparin  interfere with clot formation, thereby interfering with the body’s natural mechanisms to stop bleeding. Aspirin and clopidogrel counter-act platelets’ action, while steroids can make blood vessels more prone to leakage.

While these medications can contribute to post-menopausal bleeding, additional (more sinister) causes need to be excluded.

Tamoxifen

Tamoxifen is often used in the treatment of breast cancer. Any abnormal vaginal bleeding while taking tamoxifen needs to be investigated with endometrial sampling (ie. taking a biopsy of the uterine lining), as tamoxifen is associated with an increased risk of endometrial hyperplasia and cancer.

What to do if you have post-menopausal bleeding

Most post-menopausal bleedings is light and short-lived. Please see your GP for initial investigations, which include a pelvic ultrasound. This helps to evaluate the pelvic organs, and the thickness of the uterine lining.

A cervical screening test (which used to be called a ‘Pap smear’) will also be needed, to exclude problems with the cervix.

Referral to a gynaecologist may be needed, especially if the endometrial thickness is 4mm or more. Your gynaecologist will take detailed history, focusing on risk factors for endometrial cancer, such as: age of first and last menstrual period; history of diabetes, hypertension, polycystic ovarian syndrome; and any family history of uterine or bowel cancers.

They will also perform a physical examination, including your height and weight, and may perform a speculum examination +/- a cervical screening test.

Your gynaecologist will also discuss the results of your pelvic ultrasound. If the thickness of your uterine lining is 4mm or more, you will need to have an endometrial biopsy taken.

If your uterine lining is thin (less than 4mm) on ultrasound, and you’ve only had a single episode of post-menopausal bleeding, your gynaecologist may choose a conservative approach (ie. watch and wait). Recurrent post-menopausal bleeding, even with a thin uterine lining, will need sampling (ie. an endometrial biopsy).

Single bleeding with thickened endometrial lining on ultrasound will always required endometrial sampling.

How is the uterine lining sampled?

The uterine lining (or ‘endometrium’) can be sampled (or ‘biopsied’) in two different ways: Pipelle; and hysteroscopy, dilatation and curettage

Pipelle

Pipelle endometrial biopsy can be done during your appointment, and is very accurate at excluding cancer. A speculum examination will be performed, and a thin 2mm tube with in-built vacuum system will be passed through the vagina and cervix, into the uterine cavity. A small sample of the uterine lining will be collected. To minimise discomfort, local anesthetic spray / injection, or a ‘Penthrox’ green whistle can be used.

Pipelle cannot remove polyps: it designed for endometrial sampling only. In 8%  of cases, an endometrial sample can’t be obtained. This may be due to the cervix being too tight / closed, or patient discomfort. There is a small chance that the endometrial sample sent to the laboratory is insufficient for a definitive diagnosis.

During and immediately after Pipelle endometrial sampling, pelvic cramping and vaginal spotting is common. If you find the procedure too uncomfortable, your clinician will stop and discuss the second option, which is hysteroscopy.

Hysteroscopy, dilatation and curettage

Hysteroscopy is performed under general anaesthetic, so you will asleep and won’t feel or remember anything. Once you are asleep, a 4mm video camera will be inserted through your vagina, through your cervix, and up into the uterine cavity. This allows your gynaecologist to look at the inside lining of your uterus. They can then take a sample of the uterine lining, during a process called a ‘dilatation and curettage’; this is akin to using a surgical spatula to gently scrape some of the uterine lining off. This endometrial sample is then sent to the laboratory for analysis.

For more information about hysteroscopy, please peruse Maven Centre’s hysteroscopy pamphlet, which is available at this link.

There are several reasons why a formal hysteroscopy, dilatation and curettage may be suggested by your gynaecologist (rather than a Pipelle biopsy). These reasons include:

• Endometrial polyp or hyperplasia is suspected on ultrasound
• Ongoing post-menopausal bleeding, despite a benign (non-cancerous) result following a Pipelle endometrial biopsy
• Patient discomfort or preference

Most samples will be processed in laboratory with 2 weeks, so management can be discussed thereafter if needed.

Frequently asked questions (FAQs)

Can fibroids and adenomyosis cause post-menopausal bleeding?

Fibroids and adenomyosis are unlikely to be the cause of your post-menopausal bleeding. This is because both fibroids and adenomyosis become quiescent following menopause.

I’ve previously had normal endometrial results. I’ve had more post-menopausal bleeding: what should I do now?

Even if you’ve previously had a normal endometrial biopsy result, if you have recurrent (repeated) post-menopausal bleeding, you need to see your GP. They will arrange a pelvic ultrasound, and may suggest another review by your gynaecologist. It could be that there is a different cause underlying your current abnormal bleeding.