Postmenopausal Bleeding

By definition, postmenopausal bleeding (PMB) is vaginal bleeding which occurs between one and three years after the last menstruation in a woman’s life. Allow me to give you an overview of underlying causes which should be considered and how to discover and manage these with modern medical treatment.

Medications such as hormone replacement therapy or hormone supportive treatment are the most common options. A woman on such treatment showing PMB should see her specialist to change the current medication to a different option after performing a pelvic ultrasound examination to exclude any other underlying condition.

If no hormonal treatment is used, it is always of utter importance to rule out endometrial hyperplasia, a precursor of endometrial cancer or even endometrial cancer itself. The latter is a neoplastic formation of the lining of the womb (uterus). It needs to be excluded as soon as possible. A pelvic ultrasound and hysteroscopy, which is a sampling of the tissue from inside the uterus, is normally done. Early diagnosis and treatment should ensure that there are no further negative implications for the woman.

Depending on their ethnic background, around 70% to 80% of women will be suffering from fibroids in their uterus at the time of menopause.

This is a benign disease which is quite often already known in the woman’s immediate family. It is inborn and might show no symptoms until the onset of perimenopause or postmenopause. During or after menopause, the drop in hormones leads to less blood flowing to the uterus and fibroids. This can cause the fibroids to degenerate (break down), and as they do, they may trigger unexpected vaginal bleeding.

It is also important to mention that the overgrowth of endometrial lining can form a polyp which can again cause discharge and bleeding. The diagnosis will always involve sonography of the female pelvis. Endometrial polyps as well as fibroids have to be established as such in a postmenopausal patient. Quite often this will be done in minor procedures performed in theatre under general anaesthetics.

Around 70 % to 80 % of women depending on their ethnic background will be suffering from fibroids in their uterus at the time of menopause.

The onset of menopause will be seen in around 80% of women at the age of 48 years. At the age 52 years, around 80% of women will be in menopause. Menopause is caused by a lack of ovarian follicle maturation. Since no follicles are being “developed”, it leads to low oestrogen levels in women, causing reduced blood flow to the mucosa of the vagina, urethra and urinary bladder. This can cause atrophy (thinning) of the superficial layers of these organs. The symptoms of a burning sensation in the vagina as well as when passing urine, combined with a bloody brownish discharge, can be seen in these patients. A specialist needs to rule out neoplastic disease in case of ongoing symptoms and vaginal postmenopausal bleeding.

Most women who have bleeding after menopause do not have cancer, but because there is about a 10% chance of cancer of the lining of the womb (uterus), it is recommended that a thorough investigation be done in an operating theatre.

The majority of the abovementioned conditions can be easily diagnosed by seeing a specialist, who will be able to rule out serious disease.

Dr Klaus Zalto Obstetrician & Gynaecologist