Menopause is defined as the stoppage of period for one year, so postmenopausal bleeding can be defined as vaginal bleeding that occurs after one year with no periods in a woman not on hormonal replacement therapy. If a woman is on hormonal therapy with estrogen and progesterone, bleeding that occurs after one year of therapy can also be considered as postmenopausal bleeding. Any kind of irregular bleeding after the year with no periods should be investigated by your physician. Although most of the time the bleeding is related to lifestyle issues such as weight gain, stress, or hormonal imbalances, other causes must be considered.
What are causes of postmenopausal bleeding?
There are several causes of bleeding including the following:
- Polyps – cervical or endometrial – a build up of tissue either in the lining of the cervix or endometrium (lining of the uterine cavity). Malignancy in polyps of the cervix or endometrium occasionally occurs but usually occurs in fairly few cases. Diagnosis can be made with ultrasound, exam if they are cervical or hysteroscopy if they are endometrial. Therapy usually is performed by removal of the polyp.
- Atrophic vaginitis or endometritis – these are due to the loss of hormonal support for the vagina and endometrium. By replacing estrogen per vagina, the symptoms and bleeding can resolve.
- Hormonal imbalance – any addition, change in dosage, or weaning off of hormonal therapies can cause bleeding to occur. When adding progesterone to estrogen therapy, an episode of spotting can occur which does not mean that the progesterone has caused the spotting but it has allowed the uterus to get rid of any build up of the lining that was already present.
- Nutrition – nutrients support the hormonal balance so if a women is deficient in certain nutrients, postmenopausal bleeding can occur. Nutrients to consider include vitamins, and essential fatty acids.
- Insulin resistance – abnormally high production of insulin by the pancreas. Insulin resistance tends to produce conversion of progesterone to estrogen which can lead to weight gain and unusual bleeding. Therapy can include daily exercise, and monitoring intake of sugar, fats, and simple carbohydrates.
- Weight changes – particularly sudden, dramatic weight loss. Estrogen stored in fat cells is released suddenly into the body and shifts the hormonal balance, thus producing the bleeding.
- Emotional stress – stress produced a shift in cortisol levels which in turn alter the balance of estrogen and progesterone. This can lead to irregular bleeding. A study done after 9/11 showed a high rate of irregular bleeding in women who were directly affected by the event. Extreme grief or anxiety has been shown to produce a similar event.
- Endometrial cancer – reported to be the cause of postmenopausal bleeding in less than 10% of all cases. Unusual bleeding can be a sign of endometrial cancer, but if postmenopausal bleeding occurs, it does not automatically mean that cancer is present. Because of the risk of cancer, all cases of postmenopausal bleeding should be investigated. There are many causes of endometrial cancer including estrogen therapy without progesterone, anti-estrogen drugs such as tamoxifen, early onset of periods, infertility, diabetes, obesity, hypertension, history of breast or colon cancer, and late menopause. Diagnosis is usually made with a biopsy of the endometrium.
How can the postmenopausal bleeding be evaluated?
- Physical exam – exam can help to rule out any cause of bleeding from the vulva and vagina. It can also determine if the uterus is enlarged or abnormal in shape.
- Pap smear – can be helpful in making sure the bleeding is not from a cervical abnormality. If endometrial cells are seen on the Pap smear, further investigation is indicated.
- Laboratory tests – complete blood count can help to determine if the bleeding is excessive, insulin level can help rule out insulin resistance, and hormonal testing might help to evaluate the balance between estrogen and progesterone.
- Evaluation of the endometrium – usually done by either ultrasound, endometrial biopsy or hysteroscopy. It is important to know whether the lining of the cavity is increased in thickness and whether further testing needs to be done
If postmenopausal bleeding occurs, please do not ignore it but see your physician and have the necessary evaluation.