Post-menopausal bleeding is vaginal bleeding that occurs at least 12 months after your periods have stopped.
Although post-menopausal bleeding is a common problem, it's not normal. There is a golden rule in medicine – ‘post menopausal bleeding should be seen as cancer until proved otherwise’.
Most likely causes
- inflammation and thinning of the vaginal lining (atrophic vaginitis) or womb lining (endometrial atrophy) - caused by lower oestrogen levels.
- cervical or womb polyps– growths, which are usually non-cancerous, that can form in the cervix (neck of the womb) or the womb itself.
- a thickened womb lining (endometrial hyperplasia) – which can be caused byhormone replacement therapy (HRT), high levels of oestrogen or by being overweight; if left untreated this can lead to development of womb cancer(also known as endometrial cancer).
- About 1 in every 10 women with post-menopausal bleeding will have uterine cancer, and in a few cases bleeding may be a sign of another type of cancer such as vulval, vaginal or cervical cancer.
Diagnosing the cause
Your GP will take a detailed history from you. You will then be refered to a gynaecologist. The following tests may be carried out:
- pelvic examination - a speculum will be inserted into your vagina, (similar to having a cervical smeartest) so your vulva, vagina and cervix can be carefully examined. Most women find this a bit uncomfortable but not painful. Swabs may be taken from your vagina and/or cervix to rule out any infection. The doctor may wish to carry out a cervical smear test as well if this is overdue.
- vaginal ultrasound scan - performed by gently inserting a fine ultrasound probe into your vagina, which you may find slightly uncomfortable. It usually takes about 10 minutes.The probe emits high-frequency sound waves to create an image of the inside of your vagina and womb, which is then displayed on a monitor. The results of this examination will then be discussed with you, and you'll find out whether you need a biopsy or hysteroscopy. This is mainly determined by the thickness of the womb lining.
- tests on a sample of the lining of the uterus (endometrialbiopsy) – If the lining of the uterus is thickened, a small sample of tissue (biopsy) may be removed using a fine, flexible plastic tube. This can cause cramps and bleeding, which usually settles very quickly. The test can be stopped if you are finding it too uncomfortable, so let the doctor carrying out the test know if you want them to stop. The speculum is then removed and an internal examination is performed. This allows the doctor to gauge the size, shape and consistency of your womb, and also assess if there is any tenderness in your pelvis.
- ahysteroscopy – this is a camera test using a fine telescope like instrument called a hysteroscope. This allows the doctor to look inside your uterus and remove a small sample of tissue for testing.The hysteroscope is passed through your cervix under either local anaestheticor general anaesthetic.
Treating post-menopausal bleeding
Treatment will depend on the cause:
Endometrial atrophy can be treated with oestrogen cream or pessaries, although treatment may not be necessary if symptoms are minimal.
If the cause is cervical polyps, they may need to be removed. This fairly simple procedure can be done as an out patient.
There are various types of endometrial hyperplasia which may be treated with hormone medication (tablets or an intrauterine system implant) or surgery to remove the uterus, cervix and ovaries (a total hysterectomy). Occasionally, if the changes are mild, no treatment may be necessary.
If bleeding is thought to be a side effect of HRT, altering or stopping the treatment may be recommended.
If the cause is uterine cancer, a total hysterectomy will often be recommended with appropriate follow up cancer treatment.
If you are in the menopause and experience ANY vaginal bleeding, however slight, it should not be ignored. A family doctor should be seen without delay and although chances are that it is not a serious problem, any sinister cause MUST be ruled out.