Medical Edge Newspaper Column

Postmenopausal Bleeding Should Prompt Visit with your Physician

May 8, 2009
Dear Mayo Clinic:
I am 54-year-old woman in good health. I assumed I was postmenopausal as I haven't had a period for nearly two years. But then last week I had a period that lasted five or six days. Should I see a doctor?

Answer:
Yes, you should see your doctor promptly to have this evaluated. If you haven't had a period for almost two years, you're definitely past menopause. Natural menopause is the date of your last menstrual period, which is confirmed after 12 consecutive months without a period. Although the average age of menopause for women in the United States is around 51, it can occur anytime between the ages of 40 and 60 years.

No amount of vaginal bleeding or spotting after menopause is normal. Most conditions that cause postmenopausal bleeding are benign, but it could be something more serious. That is why consulting your doctor is important.

The most frequent cause of vaginal bleeding after menopause is thinning of the tissues that line the uterus. This thinning results from the decrease in estrogen levels that women experience after menopause. The condition is common and usually doesn't require treatment. In addition, the vaginal lining can thin out significantly after menopause, to the point of causing some vaginal spotting. Vaginal estrogen can be used to treat this condition.

You didn't mention if you are on hormone therapy. Some medications, like hormone therapy for menopause and blood thinners, can also cause vaginal bleeding.

Uterine polyps or uterine fibroids could be another possible cause. If present, uterine polyps need to be removed, because in rare cases they can be a potential site of cancerous growths. Fibroids are noncancerous (benign) growths in the uterus. They tend to shrink after menopause when the level of estrogen drops and typically don't require treatment. However, fibroids that grow and are associated with bleeding after menopause need to be removed because of potential malignant changes.

Another cause of postmenopausal bleeding is overgrowth of the uterine lining (endometrial hyperplasia). Women of menopausal age are at an increased risk for this condition, particularly if they are obese or have had prolonged exposure to estrogen during their reproductive life. These include women whose periods began at an early age, those who had late menopause, women who have never given birth, or who have had polycystic ovarian syndrome.

If present, endometrial hyperplasia should be identified and treated as soon as possible. Women with this condition are at an increased risk for developing cancer of the uterine lining (endometrial cancer). Endometrial hyperplasia may require surgery, but sometimes it can be managed with medication and close follow-up monitoring.

One in 10 women with postmenopausal bleeding has endometrial hyperplasia, and another one in 10 has endometrial cancer. These are the main reasons why evaluation of postmenopausal bleeding is necessary as soon as possible. Early diagnosis gives the best chance of cure. To find out what's behind your bleeding, make an appointment to see your doctor.

Also, all women at or near the age of menopause should see their doctors regularly for a clinical breast exam, mammogram, cervical cancer screening with a Pap smear and a pelvic exam, along with regular monitoring of blood sugar, cholesterol levels, and thyroid function. Having these tests and examinations on a regular basis can help identify gynecologic concerns, as well as other conditions such as diabetes, thyroid disorders and high cholesterol in their early stages when they are more readily treatable. Risk assessment and prevention of osteoporosis can also be discussed.

In addition, women who have physical and emotional symptoms associated with menopause, such as hot flashes, vaginal dryness, mood changes, sleep problems or changes in sexual function, should also seek help from their doctors. These symptoms are common in women going through menopause, and there are effective treatments available that can make the transition easier.

— Rosalina Abboud, M.D., Obstetrics and Gynecology, Mayo Clinic, Rochester, Minn.