Bleeding after menopause something you need to worry

Women need to know postmenopausal bleeding is never normal, and it may be an early symptom of endometrial cancer. Any bleeding, even spotting, should trigger a visit to your doctor as soon as possible. Don't wait to make an appointment until after the holidays or even next week. Do it today.

Why do some women bleed even after menopause?

The bleeding that is experienced by women after the menopause is called postmenopausal bleeding. Postmenopausal bleeding (PMB) is a common clinical problem and with increasing longevity, the incidence is on the rise in our population.

The reasons can be presence of polyps, thin atrophic endometrium, endometrial hyperplasia or endometrial cancer.

Abnormalities of the cervix can also present as bleeding in postmenopausal age. Sometimes infections, medical disorders (e.g., liver cirrhosis), decubitus ulcer in cases of uterovaginal prolapse, neglected pessary and forgotten intra uterine device can present as postmenopausal bleeding.

It is not normal to bleed after post-menopause. Women with postmenopausal bleeding should always see a doctor, in order to rule out serious medical problems even if there is spotting. However, 80 – 90 per cent of the women with postmenopausal bleeding have benign conditions

Why you shouldn't ignore postmenopausal bleeding

There are both categories of women, some who report the first episode and some who report after multiple episodes. Any bleeding experienced after one year of menopause should be reported to a gynaecologist. The most important responsibility of the gynaecologist in such a case is to rule out uterine cancer.

However, one must understand that women with risk factors like nulligravida, obesity, diabetes, taking exogenous estrogens or on tamoxifen (given for breast cancer) or women who attain menopause late have higher chance of cancer and should approach doctors early.

As the first line of investigation Transvaginal ultrasonography (TVS) is the recommended to assess the endometrial lining thickness. The normal cut off is 4 mm, and any report more than 4 mm should be investigated. Endometrial biopsyis recommended preferably along with hysteroscopic evaluation.

Endometrial cancer and postmenopausal bleeding are they co-related

Postmenopausal bleeding until proved otherwise should be considered abnormal, except in those taking hormone replacement therapy. Postmenopausal bleed is the most common symptom of endometrial carcinoma. 5-10 per cent of Postmenopausal bleeding are reported to be endometrial cancer.

How can the bleeding be controlled?

Postmenopuasal bleeding which are not due to cancer can be treated by medication or surgery. If bleeding is due to polyps, hysteroscopic polypectomy is required to remove them. In majority of the cases, these polyps are non-cancerous and hysteroscopic removal is sufficient. They subsequently do not require any hysterectomy.

Endometrial atrophy can be treated with hormones such as oestrogen cream. If postmenopausal bleeding is due to endometrial hyperplasia, it is suggested to be treated with hormone treatment (progesterones) or hysterectomy. If postmenopausal bleeding is due to hormonal replacement therapy, HRT may be decreased/stopped depending upon the condition.

After taking medications also it may and in these situations sometimes one may need to do hysterectomy. Endometrial bleeding is generally due to local pathology in the uterine lining. Presence of hormones secondary to ovarian cysts can also present as postmenopausal bleeding.

What is the treatment for endometrial cancer?

Endometrial cancer is treated with surgery (hysterectomy along with removal of both ovaries, pelvic and para aortic lymph nodes). If the disease is detected early, then cure rates are good. Some advance cases may require radiotherapy and chemotherapy. Follow up after surgery is as essential as the surgery itself. Thus, all women operated for uterine (endometrial) should also come for follow up check-ups.

(-The author is a senior Gynecologist, Laparoscopic and Robotic Surgeon)