Bleeding Problems: Postmenopausal Bleeding
Postmenopausal bleeding (PMB) is vaginal bleeding occurring after twelve months of having no bleeding, when the bleeding has stopped due to the menopause.
What Should I Do?
If you have noticed postmenopausal bleeding, you should arrange an urgent appointment with your own doctor. Your history and examination may indicate a cause but usually urgent referral to a gynaecologist would be arranged for further investigation. It is a common problem representing 5% of all gynaecology outpatient attendances. In many women, simple causes are found such as vaginal atrophy, but serious causes must be considered and excluded.
- Non-gynaecological causes including trauma or a bleeding disorder.
- Use of hormone replacement therapy (HRT).
- Vaginal atrophy—thinning of the vaginal walls due to the menopause.
- Thickening of the womb lining (endometrium)
- Womb cancer
- Womb polyps or cervical polyps.
- Cervical cancer.
- Uterine sarcoma (rare).
- Ovarian cancer, especially estrogen-secreting ovarian tumours.
- Vaginal cancer is very uncommon.
- Cancer of vulva may bleed, but the lesion should be obvious.
Risk factors for endometrial (womb) cancer
- Tamoxifen has an anti-estrogen effect on the breast, but an estrogenic effect on the womb and can stimulate the womb lining.
- Polycystic ovarian syndrome can increase risk.
- Hereditary non-polyposis colorectal carcinoma.
- Obesity combined with diabetes.
- Use of combined oral contraceptives decreases risk.
Check your BMI (Body Mass Index) with our BMI calculator.
Transvaginal Ultrasound Scan
Where sufficient local skills and resources exist, transvaginal ultrasound scan (TVUS) is an appropriate first-line procedure to identify which women with PMB are at higher risk of endometrial cancer.
The womb lining in postmenopausal women is much thinner than in premenopausal women. Thickening of the endometrium may indicate the presence of pathology. In general, the thicker the endometrium, the higher the likelihood of important pathology, ie endometrial cancer being present and further investigation being required.
view a video clip of an ultrasound scan - 244Kb
A definitive diagnosis in postmenopausal bleeding is made by taking a sample of the womb lining which is then examined in the laboratory. Usually a sample can be taken by a sampling device as an outpatient procedure. Occasionally a general anaesthetic (GA) will be required.
Hysteroscopy and biopsy is the preferred diagnostic technique to detect polyps and other benign lesions. Hysteroscopy is usually performed as an outpatient procedure, although some women will require GA. A significant development has been direct referral to 'one stop' specialist clinics where the most appropriate investigation can be carried out at one visit. Following such assessment, reassurance can be given or further investigations or treatment can be discussed and arranged.
view a video clip of a hysteroscopy - 345Kb
Women with breast cancer who take tamoxifen on a long-term basis are at increased risk of endometrial cancer. Women taking Tamoxifen who have postmenopausal bleeding should be investigated urgently but ultrasound scan is not as helpful in such women as it is in those with postmenopausal bleeding who are not taking Tamoxifen. In this situation, Hysteroscopy with biopsy is preferable as the first line of investigation.