Post-menopausal bleeding

Post-menopausal bleeding refers to any vaginal bleeding that occurs after a woman has stopped having periods for more than 12 months.

Key points

  • If you have any vaginal bleeding after menopause, you need to see your doctor.
  • Vaginal bleeding may indicate that you have endometrial cancer.
  • Women taking menopause hormonal therapy (formerly known as hormone replacement therapy) are at greater risk of endometrial cancer.
  • Women taking tamoxifen are also at greater risk of endometrial cancer.

What is post-menopausal bleeding?

Menopause occurs in most women about the age of 50, but it can happen earlier. If you are over 40 and stop having periods, this is probably due to menopause.

Menopause happens when you stop producing eggs from your ovaries and the amount of female hormone called oestrogen decreases.

This affects your uterus and vagina. The lining of your uterus becomes much thinner and you stop having your periods. The wall of your vagina can also become a bit thinner. This is called atrophic vaginitis and can lead to bleeding from the vagina, for example, bleeding after sex.

In some situations, the lining of your uterus, which is called the endometrium, can continue to grow even after menopause. This growth is called endometrial hyperplasia and can lead to endometrial cancer.

What causes post-menopausal bleeding?

Atrophic vaginitis

This is the most common cause of post-menopausal bleeding (PMB). About three quarters of women with PMB will have atrophic vaginitis. See more about bleeding after sex.

Endometrial cancer

About 10 per cent of women with PMB will have endometrial hyperplasia or endometrial cancer. Early diagnosis and treatment of endometrial cancer is very successful.

Cervical or endometrial polyps

Polyps are localised areas of abnormal growth of the lining of the uterus. They are usually not cancerous, but endometrial polyps can become cancerous. They can also make it difficult to know if there is cancer present.

Menopause hormonal therapy

Menopause hormonal therapy used to be called hormone replacement therapy. Some of the symptoms of menopause can be treated with oestrogen. To do this safely, it is necessary to combine oestrogen and progesterone to mimic your monthly cycles. However, by adding in progesterone, a woman will continue to have periods. Some women do not want to have periods and prefer to just take oestrogen. Other women may take over-the-counter medications that contain oestrogen.

Tamoxifen

Tamoxifen is a medicine used to treat breast cancer. It is a very weak oestrogen. In breast tissue, tamoxifen protects against the effect of oestrogen, but in the uterus, tamoxifen acts like oestrogen. For this reason, women taking tamoxifen are more at risk of developing endometrial cancer. If you are using tamoxifen and you have any abnormal vaginal bleeding, you need to see your doctor immediately.

Cervical cancer

Post-menopausal bleeding can also be due to cervical cancer cancer, but this is rare.

Bleeding disorders

If you have an underlying bleeding problem, for example, from taking too much anticoagulant medication, you may have vaginal bleeding. Usually you will have bleeding from other places as well, especially your nose, or your gums when you brush your teeth.

How is post-menopausal bleeding investigated?

History

If you have PMB, you should see your doctor. They will ask you about the bleeding and about any medicine you are taking, especially tamoxifen.

Examination

Your GP will also need to do a gentle pelvic examination. This is to look for any causes of bleeding. If the bleeding appears to be due to atrophic vaginitis and there are no other causes seen, then an ultrasound scan is arranged. If this is normal then no further investigation may be necessary.

Investigations

The main way of diagnosing endometrial cancer is by your doctor taking a sample of the lining of your uterus. This is similar to having a smear test. A regular smear test will not be able to reliably diagnose an endometrial cancer, but occasionally a smear test might find abnormal cells that suggest an endometrial cancer. Sometimes an ultrasound will also be performed.

Ultrasound

An ultrasound is a very good way of looking at the lining of the uterus. If the lining of the uterus is less than 5mm thick, then the chance of a cancer of the endometrium is very low.

Pipelle biopsy

This is a small plastic tube like a straw, which can be used to obtain some cells from the lining of the uterus. No anaesthetic is needed for this procedure.

Dilatation and curettage (D&C)

This procedure is usually done if it is not possible to obtain a sample of cells when a pipelle is performed or if an ultrasound shows that the lining of the uterus is too thick. It usually requires a light anaesthetic.

Hysteroscopy

A hysteroscopy is a procedure when a small telescope is inserted through the cervix and into the uterus. Polyps can be removed at the same time under direct vision. The telescopes are now so small that this procedure can be done in the outpatient’s clinic, but usually it will be performed with a light general anaesthetic. 

What is the treatment for post-menopausal bleeding?

 The treatment for PMB will depend on the findings.

Atrophic vaginitis

If there are no obvious causes on examination and if the ultrasound scan is reassuring, then your GP may decide that no treatment or investigation is necessary. Often the bleeding will only happen once.

If the bleeding occurs again then you will be referred to the gynaecology clinic.

Atrophic vaginitis can be treated with the local application of some oestrogen cream for a few weeks. This can be repeated if required. Your GP may also talk to you about menopause hormonal therapy. There are risks and benefits for menopause hormonal therapy so you need to think carefully about whether or not you want to take it and talk it through with your doctor before making your decision.

Cervical polyps

Cervical polyps may require an operation to remove them.

Endometrial hyperplasia or cancer

If the biopsy shows that the lining of the uterus is abnormal further treatment will be required for endometrial cancer.

 How can I help myself if I have post-menopausal bleeding? 

  • See your GP as soon as possible if you have any postmenopausal bleeding.
  • Have regular cervical smear tests.
  • Discuss the risks and benefits of menopause hormonal therapy with your doctor or family planning before deciding whether or not to take it.

 Learn more about post-menopausal bleeding

Postmenopausal bleeding NHS Choices, UK, 2014
Hysteroscopy Patient Info, UK, 2015
Pipelle Biopsy HealthInfo, New Zealand, 2016

Credits: Dr Jeremy Tuohy.