Introduction and definition

Menopause is when there have been twelve months without a normal menstrual period.¹ Menopause in women usually happens between the ages of 45-55 years but can be earlier.¹ The menopause can be natural or can occur after surgery to remove the womb (uterus) or ovaries or after certain treatments like chemotherapy.¹ Post menopausal bleeding (PMB) is bleeding at least 12 months after the last period/bleed.²,³ There are a number of causes for this, but importantly, in about 10% of cases, this can be a sign of cancer and therefore warrants urgent investigation.² During the time of menopause, there is reduction in the hormones oestrogen and progesterone.⁴ 5-11% of post-menopausal women will experience PMB.⁴ This article will detail symptoms, possible causes, treatments and what steps to take.

Post-menopausal bleeding (PMB) can be seen as fresh blood, spotting, pink or brown discharge, and so if any of these have been present 12 months after the last period /bleed, then it is important to contact your GP or healthcare provider.⁵

Causes of postmenopausal bleeding

Vaginal atrophy 

During the time of menopause, there is a reduction in oestrogen (a hormone), which causes changes to the genital tract, amongst other symptoms. The lining of the womb and vagina is thin, becoming irritated and inflamed more easily. This can lead to chronic inflammation, which is then prone to bleeding.²  This is the most common cause of PMB.²

Polyps

These are benign (non-cancerous)  growths that can cause PMB and can originate from the vagina, cervix or the uterus (womb).²

Endometrial thickening

The lining of the womb (uterus) is called endometrium. This means the womb lining, or endometrium, is thickened and is more likely to bleed. This can be the result of changes like cancer in the lining of the womb and as a side effect from certain medications.². Excessive intake of soy (containing phytoestrogens) has been associated with endometrial thickening as there is excessive oestrogen production from certain types of ovarian and adrenal gland tumours.²

Cancer

Cervical, ovarian (less commonly),  and endometrium (womb) cancer can present with vaginal bleeding after menopause with 5-15% of PMB due to endometrial cancer.^2,5 Therefore it is essential that any woman that has vaginal bleeding a year or more after menopause has investigations to ascertain the cause. It is also important to keep up routine smears to check on the cervix's health.

Less common causes of PMB include:

• Infection: Although less common in high-income countries, tuberculosis of the endometrium can present with PMB.²
• Hereditary: A specific  hereditary condition (inherited through families) called Hereditary Non- Polyposis colorectal cancer syndrome has a lifetime risk of 40-60% of endometrial cancer that could present with PMB.² 
• Other site cancer: Presentation of urological or rectal cancers that may present as perceived PMB.²

Risk Factors for endometrial cancer include unopposed oestrogen therapy.

Tamoxifen, which is a drug that is sometimes used in breast cancer, has a positive oestrogen effect on the uterus.² 

Obesity and increasing age are also risk factors for endometrial cancer.²

Assessment

Any women experiencing PMB should contact their local doctor. There the GP will take a history to include risk factors for excess oestrogen and examine the abdomen and genital tract. If post-menopausal bleeding is suspected but no obvious cause seen on examination, an urgent referral will be made to local pathways specifically for PMB. In many areas a one stop clinic is available where patients can be seen, investigated and sometimes treated (dependent on findings).³ 

Investigations

A transvaginal ultrasound is an integral part of the investigations. The lining of the endometrium can be visualised and measured where if an endometrial thickness is greater than 4 mm, a further evaluation must be required as stated by the American college of Obstetrics and Gynaeoclogists.³ An endometrium thickness of less than (or equal to) 4 mm can reasonably exclude endometrial cancer.⁵

Tissue Sampling is the definitive diagnosis to assess the lining of a thickened endometrium although it would also likely be performed if there is persistent PMB despite a normal endometrial thickness.²,³ Hysteroscopy allows the direct visualisation of the uterus wall/cavity and also allows for tissue sampling under visual guidance rather than blind sampling.³ Hysteroscopy is the passage of a camera through the vagina and via the cervix to enter the uterus. With advances in technology, hysteroscopy and sampling can be performed in the outpatient clinic. If this is not possible it can be performed in an in-patient setting under general or regional anaesthesia.³ The tissue sampled is then examined by a histopathologist to assess if there are cancerous or precancerous cells present. 

Treatment

This is dependent on the cause of the bleeding. 

Vaginal atrophy 

Vaginal oestrogen reverses the thinning of the genital passages affected after menopause.^{2 6} A small amount is absorbed systemically. In those women who are on hormone replacement therapy (HRT) orally/ transdermally, they may still need to use topical vaginal preparations for control of symptoms of atrophic vaginitis.⁶

Polypspectomy

Polypectomy (removal of the polyp) can be done at the time of hysteroscopy. This should be sent for histopathological testing for assessment of any precancerous/cancerous changes.²

Endometrial thickening

If, after sampling of the tissue, no concerning features are found, a progesterone releasing system can be inserted into the vagina, for example levonorgestrel intrauterine system (LNG-IUS), this inhibits further growth of the endometrium lining. ⁷

Cancer

Treatment will depend on many factors including but not limited to the site of the cancer, individual aspects of the patient preceding health and if the cancer has spread. 

General

It is important to investigate any unusual gynaecological bleeding. This article focused on bleeding after menopause. It is important to continue routine smears to assess for any changes at the cervix that could develop into cancer. 

Summary

Bleeding after menopause is defined as bleeding twelve months after the last period /bleed and although most causes are benign, cancer needs to be excluded. It is therefore imperative that anyone suffering with these symptoms contact their local doctor for assessment.