By Dr. M V R Shailaja
Mrs X comes to my clinic for an appointment but it’s not for her regular annual visit. She is here for vaginal bleeding that has taken her by surprise. She says she attained menopause a couple of years ago. She looks anxious and worried and asks what it could be?
Most women who experience bleeding after menopause are understandably concerned. After all, they thought they were done with it. Menopause is officially confirmed if it has been 1 year since your last menstrual period.
Any vaginal bleeding after the menopause is called postmenopausal bleeding or PMB. Postmenopausal bleeding can range from light spotting that is pinkish-grey or brown, all the way to a heavy flow, like a regular period. Most of the time, there is no pain with the bleeding.
No matter what the symptoms are, one may need to consult a gynaecologist if this happens.
The gynaecologist may then ask questions like when did you attain your menopause? Are you using any other medications? Do you have any other health problems?
Once the detailed history is taken, the gynaecologist will do pelvic examination where they look at the vagina and cervix and feel for the size of the uterus to find any obvious cause of the bleeding.
Further evaluation depends on the patient’s age and how long they have been experiencing the symptoms and the amount of bleeding. Pelvic ultrasound or a biopsy to be taken from the lining of the uterus may then be suggested by the gynaecologist. Sometimes they may suggest both. This biopsy can be taken in the OPD without anaesthesia (pipelle) or under anaesthesia.
Some cases may call for more complex procedures like diagnostic hysteroscopy with dilatation and curettage.
In this procedure, the gynaecologist will place a camera into the vagina, through the cervix, and into the uterus. Cells are removed from the lining of the uterus. This tissue sample is sent to a lab for testing.
One reason for PMB could be that the tissue of the vagina and vulva has got thinner. This can happen due to hormone changes. If one experiences the bleeding after sex, it may be from friction against this thinner sensitive skin - but the gynaecologist should still do full evaluation to be sure.
Topical estrogen cream often resolves this kind of post-menopausal bleeding. Using lubrication during intercourse can help as well. If the lining of the uterus is super thin, one may even consider giving hormone therapy.
Polyps also can cause vaginal bleeding. If these non-cancerous benign growths are discovered in the uterus or on the cervix, one might need surgery to remove them.
Less commonly, in some cases, the cells of the lining can become abnormal, leading to cancerous changes and this may be the cause of bleeding. 1 in 10 women with PMB can have cancerous cells in the lining of the uterus.
Cancer is the most serious but least likely cause of bleeding after menopause. If testing finds cancerous cells, the treatment depends on the stage of cancer. The treatment may range from removal of uterus to extensive treatment depending on the stage.
If cancer is found it is usually at an early stage and treatment can cure it.
Even if it is not cancer, one may need future ultrasounds to keep an eye on things. If the follow up tests are bothersome and other treatments haven't worked then one may need removal of uterus or hysterectomy.
If you have PMB, act now and don’t neglect it.
Bleeding after menopause is not normal, so take it seriously and consult your gynaecologist. Chances are there’s no reason for panic. But we can be sure only after careful evaluation.
This article was published in association with Rainbow Children’s Hospital.