Bleeding after the menopause

(Postmenopausal Bleeding)

Introduction

Menopause is defined as the permanent cessation of menstruation for 12 consecutive months, typically occurring around age 50–52.

• Any vaginal bleeding after menopause is considered abnormal.

• Postmenopausal bleeding (PMB) is one of the most important warning signs of endometrial carcinoma but is more often due to benign causes.

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Causes of Postmenopausal Bleeding

1. Benign Gynecological Causes

• Atrophic endometritis/vaginitis: Thinning of endometrium/vaginal mucosa due to low estrogen → fragile tissues bleed easily.

• Endometrial or cervical polyps: Common, usually benign.

• Fibroids: Can continue to cause bleeding in some women after menopause.

2. Malignant / Precancerous Causes

• Endometrial carcinoma (most important, must be excluded).

• Endometrial hyperplasia with atypia.

• Cervical cancer.

• Ovarian tumors producing estrogen (e.g., granulosa cell tumor).

• Vaginal cancer (rare).

3. Hormone-Related

• Hormone replacement therapy (HRT).

• Tamoxifen (used in breast cancer) → causes endometrial thickening.

4. Systemic / Other Causes

• Bleeding disorders (anticoagulant therapy, thrombocytopenia).

• Trauma or foreign body.

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Clinical Features

• Main symptom: Any bleeding (spotting, light, heavy, single or recurrent) after menopause.

• May appear as:

  • Pink, brown, or bright red discharge.

  • Spotting after intercourse.

  • Recurrent or persistent episodes.

• Associated symptoms:

  • Pelvic pain, bloating, abnormal discharge.

  • Weight loss, fatigue (suggest malignancy).

  • Vaginal dryness, itching, painful intercourse (atrophic vaginitis).

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Diagnostic Approach

1. History

• Menstrual and menopause history.

• Medications: HRT, tamoxifen, anticoagulants.

• Risk factors for endometrial cancer: obesity, diabetes, hypertension, nulliparity, late menopause, unopposed estrogen.

• Associated symptoms: pain, discharge, systemic illness.

2. Examination

• General: anemia, weight loss.

• Abdominal exam: masses, ascites.

• Speculum exam: cervix (polyps, lesions, atrophy).

• Bimanual exam: uterine size, adnexal masses.

3. Investigations

• Transvaginal ultrasound (TVUS):

  • First-line investigation.

  • Endometrial thickness >4–5 mm is abnormal and requires biopsy.

• Endometrial biopsy:

  • Gold standard for diagnosis.

  • Office Pipelle biopsy or dilation and curettage (D&C).

• Hysteroscopy:

  • Direct visualization, allows polyp/fibroid removal and targeted biopsy.

• Cervical cytology (Pap smear): Cervical pathology.

• Blood tests: CBC (anemia), coagulation profile, thyroid tests.

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Management and Treatment

Treatment depends on the cause.

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A. Benign Causes

1. Atrophic Vaginitis / Endometritis

• Topical estrogen therapy:

  • Estradiol 10 mcg vaginal tablet once daily for 2 weeks, then twice weekly.

  • Estriol cream 0.5 mg applied intravaginally daily × 2 weeks, then twice weekly.

• Vaginal moisturizers and lubricants.

2. Endometrial or Cervical Polyps

• Hysteroscopic polypectomy.

3. Fibroids

• Usually shrink after menopause; if symptomatic → myomectomy or hysterectomy.

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B. Malignant / Precancerous Causes

1. Endometrial Carcinoma

• Mainstay: Total hysterectomy with bilateral salpingo-oophorectomy (TH-BSO).

• Staging surgery may include lymph node dissection.

• Adjuvant radiotherapy or chemotherapy (e.g., Carboplatin + Paclitaxel) depending on stage.

2. Endometrial Hyperplasia with Atypia

• Definitive: Hysterectomy.

• If fertility preservation desired (rare in PMB):

  • Medroxyprogesterone acetate 10–20 mg orally daily.

  • Levonorgestrel intrauterine device (LNG-IUS).

3. Cervical Cancer

• Early stages: surgery (radical hysterectomy).

• Advanced: chemoradiation (Cisplatin-based).

4. Ovarian Granulosa Cell Tumor

• Surgical removal (TH-BSO).

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C. Hormone-Related Causes

• HRT-related bleeding:

  • Adjust regimen or switch preparation.

  • Rule out endometrial pathology if persistent.

• Tamoxifen-induced bleeding:

  • Requires TVUS + biopsy to exclude endometrial cancer.

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D. Systemic / Other Causes

• Correct coagulopathies, adjust anticoagulant dose.

• Trauma → local repair.

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Complications

• Iron-deficiency anemia from recurrent bleeding.

• Anxiety and reduced quality of life.

• Delayed cancer diagnosis → poor prognosis.

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Prognosis

• Atrophic causes: Excellent, easily treated with local estrogen.

• Polyps/fibroids: Good after removal.

• Endometrial carcinoma: Prognosis depends on stage at diagnosis:

  • Stage I: >90% 5-year survival.

  • Stage IV: <20% 5-year survival.

• Cervical cancer: Early detection = high survival rates.

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Patient Education

• Any bleeding after menopause must be investigated.

• Most cases are benign, but cancer must be excluded.

• Regular gynecological check-ups, Pap smears, and timely evaluation of symptoms.

• Maintain healthy weight, control diabetes, and avoid unopposed estrogen use.

• Report recurrence or persistence of bleeding immediately.