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Post-Menopausal Bleeding

Postmenopausal bleeding (PMB) is defined as any vaginal bleeding that occurs after 12 months of amenorrhea (absence of menstrual periods) in a middle-aged woman.  Episodes of vaginal bleeding are also characterized as postmenopausal when they occur in younger women (under the age of 40) who have had no menstrual periods for a year and menopause from premature ovarian insufficiency has been diagnosed.

Postmenopausal bleeding – including just pinkish-gray or brown vaginal spotting – is not normal, even if painless, and must always be investigated.  Postmenopausal women who are unsure if the bleeding is vaginal – the blood may be coming from the bladder or rectum – typically still consult with their the gynecologist to evaluate the bleeding, no matter the source.

When the uterus is the source, postmenopausal bleeding lies within the broad spectrum of abnormal uterine bleeding. But, postmenopausal bleeding can also be caused by cervical or vaginal pathology.

  • Thinning of the uterine lining, also known as the endometrium (endometrial atrophy)
  • Thinning of the vaginal lining (vaginal atrophy):  the most common reason for PMB together with endometrial atrophy
  • Uterine polyps
  • Infection of the uterine lining (endometritis)
  • Excessive overgrowth of the uterine lining (endometrial hyperplasia)
  • Uterine cancer (either from the endometrium or the muscle of the uterus, the myometrium)
  • Medications such as hormone therapy, tamoxifen (used to prevent recurrent breast cancer), blood thinners, and, more rarely, some mental health medications
  • Non-structural causes, like abnormal clotting

Other causes of bleeding during the postmenopausal period:

  • Bleeding from benign or malignant pathology in the bladder or urethra
  • Bleeding from benign or malignant pathology in the rectum or anus

As with all good medical practice, assessment of postmenopausal bleeding starts with a thorough personal medical and gynecologic history, including the more recent history of how and when the vaginal bleeding occurred (or is occurring), and if there are any associated symptoms, such as abdominal bloating or abdominopelvic pain.  When giving a gynecologic history, it is important for a woman to be able to say when she went through menopause because the longer it’s been the greater the cause of concern and the more testing the gynecologist may need to do.

Next, a general physical exam and a thorough gynecologic exam are done. The physical exam can reveal evidence of a clotting disorder with the finding of multiple bruises on the skin or suspicion of a malignancy in the pelvis if an abdominal or pelvic mass or enlarged peripheral lymph nodes are found.  A thorough gynecologic exam includes careful inspection of the vulva, urethra, and anus, a speculum exam to evaluate the vagina and cervix, and a bimanual pelvic exam (including a rectovaginal exam) to assess the size, contour, and mobility of the uterus and to feel for any masses in the pelvis, including any that may be lurking behind the uterus near the rectum.

Following the gynecologic exam, evaluation for post-menopausal bleeding will depend on the woman’s age, how long it’s been since her menopause, and how much vaginal bleeding she’s been experiencing.  A transvaginal pelvic ultrasound, or sonogram, is usually performed to closely examine the uterus: its size and contour, the contents of the uterine cavity (is there fluid in it? is there a polyp? is there a mass?), and the texture and thickness of the lining of the uterine cavity, the endometrium (the endometrium is where most pathology of the uterus occurs). Because a transvaginal pelvic sonogram in a postmenopausal woman with vaginal bleeding has a very high negative predictive value (meaning, if the sonogram is negative, then it is highly unlikely there is any uterine pathology), it is a reasonable first approach.

If the thickness of the endometrium as measured by the pelvic sonogram is greater than 4 mm (which is about an eighth of an inch), pathology may be present, so it is recommended that an office endometrial biopsy be performed to obtain a sample of the endometrium that can be analyzed under the microscope.  If a woman has an endometrial thickness under 4 mm, an endometrial biopsy need not be done, but it should be strongly considered if the vaginal bleeding persists or recurs.  An endometrial biopsy is usually easily obtained transvaginally by suctioning out a small sample of loose endometrium via a thin plastic catheter that is placed into the uterine cavity through the cervical canal.  However, it isn’t always possible to complete a meaningful transvaginal pelvic sonogram with a reliable measurement of the endometrial thickness or obtain an adequate office endometrial biopsy.  It can be difficult to get an accurate sonographic endometrial measurement or a sufficient endometrial biopsy sample because there may be fibroids that distort the anatomy of the uterine cavity, or previous uterine surgery that caused uterine cavity scarring, or severe vaginal narrowing from atrophy, or marked obesity.  Alternative methods of evaluation would then have to be used.

A pelvic ultrasound done for postmenopausal bleeding has the benefit of being able to closely examine not only the uterus, but also the ovaries, bladder, and pelvic cavity.  While ovarian pathology is typically not the direct cause for postmenopausal bleeding, incidentally discovered pathology in the ovary, like a cystic or a solid mass, might be related to the PMB—or not— and warrant further evaluation.  Further evaluation may also be needed if ultrasound shows an abnormal amount of free fluid in the pelvis, which could be a sign of a pathologic process involving the ovaries, tubes, or other organs.  Finally, surveying the bladder during a pelvic sonogram can help discover an asymptomatic stone or tissue mass in the bladder cavity that may be helpful in diagnosing the cause of “postmenopausal bleeding,” with the the bleeding, in this case, really being of urinary tract origin instead of gynecologic.  Appropriate referral to a urologist would follow in this situation.

While the role of the office endometrial biopsy is to detect pathology in the uterine cavity, it has its shortcomings because it is a blind biopsy.  Ultimately, as acknowledged by the American College of Obstetricians and Gynecologists in 2012, the primary role of an endometrial biopsy in a woman with abnormal uterine bleeding is to determine whether a cancer or pre-cancer is present in the uterine cavity.  For an endometrial biopsy to have a high overall accuracy, the sample has to be adequate and the malignancy has to involve at least 50% of the surface area of the endometrium.  A small malignancy may be missed by an endometrial biopsy because it samples a very small percentage of the endometrium.  Thus, an endometrial biopsy that’s negative for cancer or pre-cancer may not be a clinically reliable result, especially if there is ongoing bleeding.  For a more accurate diagnosis of the cause of postmenopausal bleeding from the uterus, it helps to visualize and examine the endometrium directly.  Office hysteroscopy makes it possible for a gynecologist to do that.

With office hysteroscopy, the gynecologist can identify discrete endometrial lesions responsible for postmenopausal bleeding, such as polyps or a focal endometrial cancer or pre-cancer.  Office hysteroscopy can also facilitate the diagnosis of a more global endometrial process, like atrophy or, again, pre-cancer or cancer.  Once a diagnosis is made, appropriate treatment can be promptly given.

The EndoSeeR Advance is a convenient and safe hand-held office hysteroscopy system that allows direct visualization of the uterine cavity without the need of anesthesia in an operating room. Directed endometrial biopsies can be done and polyps removed, which help make the diagnosis without having to go to the operating room.

We at Adaptive Gynecology understand how concerning post menopausal bleeding can be. Our goal is to allay concerns by identifying the cause as easily and conveniently possible and promptly creating an appropriate treatment plan.

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