When a woman has had no periods for 12 consecutive months she is considered to be “Postmenopausal”.
Most women become menopausal naturally between the ages of 45 and 55 years, with the average age of onset at around 51 years.
Bleeding after menopause, also known as postmenopausal bleeding (PMB), is a condition characterized by vaginal bleeding in women after 12 months of menopause.
In most cases, PMB is harmless, but sometimes it may be secondary to an underlying disorder. Hence bleeding after menopause should be carefully investigated.
Although it is common for women to have a change in their periods (lighter or heavier, shorter or longer, closer together or further apart) leading up to the menopause (also called the “perimenopause”), a persistent change to your normal pattern of bleeding for more than 1-2 months should also be thoroughly investigated. Although most of the time this abnormal bleeding is due to a change in the level of your ovarian hormones (oestrogen and progesterone), investigation is required to rule out abnormalities such as polyps, pre-cancers, or cancers of the gynaecological organs.
Common causes of bleeding around this time include
- Thinning of the tissues lining the uterus (endometrial atrophy) or vagina (vaginal atrophy) due to decrease in oestrogen levels
- Medications such as hormone replacement therapy
- Abnormal hormone levels (eg: progesterones, prolactin, thyroid hormones)
- Uterine fibroids
- Cervical and endometrial polyps
- Infection and inflammation of the uterine lining (endometritis)
- Endometrial hyperplasia – this occurs when the endometrium, the lining of the uterus, becomes too thick. It is not cancer, but in some cases, it can lead to cancer of the uterus.
- Cancer of the uterus, including endometrial cancer and uterine sarcoma
- Cancer of the cervix or vagina
- Non-gynaecological causes such as pelvic trauma or bleeding disorder
- Bleeding from the urinary tract or rectum
Investigations
The cause of PMB can be determined by
- Medical history and physical examination.
- Transvaginal ultrasound
- Endometrial biopsy: This involves the insertion of a fine tube inside the uterus for withdrawing a sample of uterine lining for laboratory analysis
- Hysteroscopy
Treatment options
Treatment of PMB depends on the underlying cause of bleeding. Anaemia (low haemoglobin) and iron deficiency should be corrected. Specific management of some of the common causes of PMB is as follow:
- Polyps: They are surgically removed via hysteroscopy
- Endometrial atrophy: Treated with hormonal medications
- Dysfunctional bleeding: treated with hormones (the OCP, or HRT, or Mirena IUD), or sometimes with endometrial ablation, or hysterectomy
- Endometrial hyperplasia: Treated with hysterectomy, or sometimes with progestogen hormones (oral tablet or Mirena IUD)
- Endometrial cancer: Treatment involves total hysterectomy i.e. surgical removal of uterus and cervix. In some cases, other organs such as ovaries, fallopian tubes, nearby lymph nodes may also be removed.
