Post-menopausal bleeding

Menopause occurs in most women about the age of 50, but it can happen earlier. If you are over 40 and stop having periods, this is probably due to menopause.

Menopause happens when you stop producing eggs from your ovaries and the amount of female hormone called oestrogen decreases.

This affects your uterus and vagina. The lining of your uterus becomes much thinner and you stop having your periods. The skin around your vulva and vagina can also become a bit thinner. This is called atrophic vaginitis and can lead to a dry feeling and bleeding from the vagina, eg, bleeding after sex.

In some situations the lining of your uterus, which is called the endometrium, can continue to grow even after menopause. This growth is called endometrial hyperplasia and can lead to endometrial cancer.

Image credit: Canva

Atrophic vaginitis

This is the most common cause of post-menopausal bleeding (PMB). About three-quarters (75%) of women with PMB will have atrophic vaginitis. See more about bleeding after sex. Atrophy refers to the thinning of tissues (as a result of less oestrogen) which can affect your vagina, the lining of your uterus (endometrium) and your urinary tract.

Endometrial hyperplasia and endometrial cancer

About 10% of women with PMB will have endometrial hyperplasia and another 10% will have endometrial cancer. Endometrial hyperplasia is when the lining of your uterus gets thicker and causes heavy or abnormal bleeding – particularly around the time of menopause or afterwards. While it isn't cancerous itself, it may increase your risk of developing endometrial cancer if it's not treated. Early diagnosis and treatment of endometrial cancer is very successful.

Cervical or endometrial polyps

Polyps are areas of abnormal growth of the lining of the uterus that stick out from the normal lining. They're not usually cancerous, but endometrial polyps can become cancerous. They can also make it difficult to know if there is cancer present in the endometrium – because they can make the endometrium look thick and abnormal on an ultrasound scan.

Menopausal hormone therapy

Menopausal hormone therapy (previously called hormone replacement therapy or HRT) can treat some of the symptoms of menopause with oestrogen. To do this safely, it's necessary to combine oestrogen and progesterone to mimic your monthly cycles and prevent the lining of your uterus growing too thick. However, by adding in progesterone, you will continue to have vaginal bleeding similar to a period.

Tamoxifen

Tamoxifen is a medicine used to treat breast cancer. In breast tissue, tamoxifen protects against the effect of oestrogen but, in the uterus, tamoxifen acts like oestrogen. For this reason, women taking tamoxifen are more at risk of developing endometrial cancer. If you're using tamoxifen and you have any abnormal vaginal bleeding, you need to see your healthcare provider immediately.

Cervical cancer

Post-menopausal bleeding can also be due to cervical cancer, but this is rare.

Bleeding disorders

If you have an underlying bleeding problem (eg, if you take too much anticoagulant medicine), you may have vaginal bleeding. If that's the case you'll usually have bleeding from other places as well – especially from your nose, or from your gums when you brush your teeth.

History

If you have PMB, you should see your healthcare provider. They will ask you about the bleeding, other symptoms you're having and about any medicine you're taking – especially tamoxifen.

Examination

Your healthcare provider will also need to do a gentle pelvic examination including a speculum examination (same type of examination as when you have a cervical smear). This is to look for any causes of bleeding. If the bleeding appears to be due to atrophic vaginitis and there are no other causes seen, then an ultrasound scan will be arranged. If the scan is normal then no further investigation may be necessary.

Investigations

If your healthcare provider is concerned you may have endometrial hyperplasia or cancer, they may recommend taking a sample of the lining of your uterus (a pipelle biopsy) during a speculum examination. A regular cervical smear test won't be able to reliably diagnose endometrial cancer, but occasionally a smear test might find abnormal cells that suggest endometrial cancer. Sometimes an ultrasound will also be performed.

• Ultrasound: An ultrasound is a very good way of looking at the thickness of the lining of the uterus. If the lining is less than 5mm thick, then the chance of a cancer of the endometrium is very low.
• Pipelle biopsy: This is taken with a small plastic tube like a thin straw, used to obtain some cells from the lining of your uterus. No anaesthetic is needed for this procedure.
• Hysteroscopy, dilatation and curettage (D&C): A hysteroscopy is a procedure where a small telescope is inserted through your cervix and into your uterus. The lining of your uterus can be seen with a camera and a sample can also be taken by curettage (which is another option for a biopsy if a pipelle biopsy wasn't possible). Polyps can also be removed at the same time under direct vision. The telescopes are now so small that this procedure can be done in the outpatient clinic, but usually it will be performed with a light general anaesthetic in a hospital setting. 

The treatment for PMB will depend on the findings.

Atrophic vaginitis

If there are no worrying causes on examination and if the ultrasound scan is reassuring, then your healthcare provider may decide that no treatment or further investigation is necessary. Often the bleeding will only happen once. If the bleeding occurs again then you'll be referred to the gynaecology clinic.

Atrophic vaginitis can be treated with vaginal moisturisers, lubricant for sexual intercourse and local application of oestrogen cream (usually used twice a week). Your healthcare provider may also talk to you about menopausal hormone therapy. There are risks and benefits for menopause hormonal therapy so you need to think carefully about whether it's right for you, and talk it through with your healthcare provider before making your decision.

Cervical polyps

Cervical polyps or endometrial polyps may require an operation to remove them. This can often be done at the time of hysteroscopy, dilatation and curettage.

Endometrial hyperplasia or cancer

If the biopsy shows that the lining of the uterus is abnormal, further treatment will be required for endometrial hyperplasia or endometrial cancer.

• See your healthcare provider as soon as possible if you have any post-menopausal bleeding.
• Have regular cervical screening tests.
• If menopausal hormone therapy is offered make sure you talk about it with your healthcare provider, or with Sexual Wellbeing Aotearoa, before deciding whether to take it.