M ,aged 60, came to see me because she had noticed fresh stains of blood on her underwear for the past 3 days.
“ I have been menopausal since the age of 52. I thought my periods would be a thing of the past. But I am alarmed to see fresh vaginal bleeding again.There was no abdominal pain or backache. I did not have any abnormal vaginal discharge. My husband and I have not had any sexual intercourse for few years,” she said.
Examination with a speculum, a metal instrument used to expose the vagina, revealed a small amount of fresh blood at the opening in the cervix (neck of the womb). A pelvic ultrasound examination showed that the uterus(womb) was small with a thin lining. The ovaries were small and appeared normal.
M was advised to have further investigations.
What is postmenopausal bleeding?
Menopause, the end of menstruation, is usually confirmed in women over 45 years of age who have not had menses for more than a year. Bleeding after this point is known as postmenopausal bleeding (PMB). It occurs in about 10% of women after menopause It is abnormal and should be evaluated thoroughly because about 10 per cent of PMB is linked to cancer of the cervix or uterus.
What are the causes of PMB?
PMB can be caused by:
Cancer of the uterus, cervix or vagina
Polyps: These are usually non-cancerous growths inside the uterus or on the cervix.
Endometrial atrophy (thinning of the uterine lining) or vaginal atrophy: Low hormone levels after menopause cause the tissues of these organs to become thin and bleeding may sometimes occur.
Endometrial hyperplasia: This is due to excessive overgrowth of the uterine lining from hormonal imbalance after menopause. Sometimes, the cells can become overactive and turn cancerous.
Infection of the uterine lining (endometritis)
Medications such as hormone therapy, tamoxifen (anti-breast cancer drug) and blood thinners.
How Is It Diagnosed?
Besides reviewing the medical history and clinical examination, the following tests are usually helpful:
Vaginal ultrasound examination: This imaging technique looks for growths in the uterus and ovaries and also evaluates the thickness of the uterine lining.
Hysteroscopy and endometrial biopsy: The hysteroscope is a thin, lighted tube with a camera attached at one end. Using this instrument, the uterine cavity is explored and abnormal tissues taken for microscopic examination.
How Is It Treated?
Treatment will depend on the cause of the bleeding.
If the bleeding is due to cancer, treatment will depend on the type of cancer and its stage. Common treatment modalities for endometrial or cervical cancer include surgery, chemotherapy and radiation therapy.
If it is due to benign polyps, removal by the hysteroscope will suffice.
In endometrial atrophy, oestrogen hormone or alternative medications may be given.
In endometrial hyperplasia, progesterone hormone medications may be prescibed.
Prevention
PMB may be benign but could be a result of a more serious condition such as cancer.
A regular gynaecological checkup after menopause can help detect conditions before they become more problematic or result in PMB. When cancers are diagnosed early, the chances of survival are higher.
M had a hysteroscopy and biopsy done. She was much relieved when the biopsy result showed that the bleeding was due to endometrial atrophy. She declined hormonal treatment as she was afraid of the side effects. She remained well with no further bleeding when she was reviewed six months after the minor surgery.