What does bleeding after menopause mean?
After the ovaries stop working, estrogen levels decrease, the lining of the uterus becomes thinner and stops being shed, so there is no more menstruation. The appearance of blood means that there is a source somewhere in the genital tract: a thin, vulnerable vaginal mucosa, a polyp, endometrial growth or tumor. Sometimes the blood is not of uterine origin at all and comes from the urinary tract or rectum - this is also important to clarify. That is why the examination begins with a general examination, and not immediately with curettage.
- Atrophy of the vaginal and uterine mucosa is the most common cause
- Polyps of the endometrium and cervical canal
- Endometrial hyperplasia
- Endometrial cancer and, less commonly, cervical cancer
- Taking hormonal drugs and anticoagulants
- Source may be in the urinary tract or rectum
Causes and risk factors
Atrophic changes explain most of the episodes: dry and thin mucous membranes are easily injured, including during sexual intercourse. The second most common group is polyps. Endometrial hyperplasia occurs when there is an excess of estrogen, the source of which in postmenopausal women is often adipose tissue, so obesity is a significant risk factor, as are diabetes and hypertension. Separately, tamoxifen is taken after treatment for breast cancer. All these conditions require different treatment, which determines the scope of the examination.
- Atrophic vaginitis and endometrial atrophy
- Endometrial and cervical polyps
- Endometrial hyperplasia
- Obesity, diabetes mellitus, arterial hypertension
- Taking tamoxifen or hormone replacement therapy
- Anticoagulants and drugs that affect coagulation
- Absence of childbirth, late menopause
How does it manifest itself?
Manifestations range from a single episode of pinkish or brown discharge on underwear to repeated heavy bleeding with clots. The intensity does not reflect the danger of the cause: scanty spotting just as much requires examination as severe bleeding. Women often note dryness and burning in the vagina, pain during sexual intercourse, and frequent urination - signs characteristic of genitourinary menopause syndrome. It is alarming if watery discharge with an odor, pelvic pain and weight loss are added.
- Scanty brown or pink discharge
- Heavy bleeding with clots
- Blood after intercourse
- Dryness and burning in the vagina
- Pain in the lower abdomen
- Watery discharge
What examinations are needed
The doctor examines the vagina and cervix to immediately see the local source of blood and takes cytology. The key method is transvaginal ultrasound measuring the thickness of the endometrium: a thin endometrium makes cancer unlikely, and a thickened one requires tissue sampling. To do this, a pipel biopsy is performed on an outpatient basis or hysteroscopy with targeted sampling and separate curettage, which is more accurate for polyps and focal changes. Additionally, a general blood test, coagulability are assessed, and if a tumor is suspected, an MRI of the pelvis is performed.
- Speculum examination and cervical cytology
- Transvaginal ultrasound with endometrial measurement
- Pipelle endometrial biopsy
- Hysteroscopy with separate diagnostic curettage
- Histological examination of the obtained tissue
- General blood test and coagulogram
Treatment
Treatment is determined by the result of histology. For atrophy, local estrogens in suppositories or creams and moisturizers are sufficient - this quickly eliminates dryness and bleeding. The polyp is removed during hysteroscopy. Hyperplasia without atypia is treated with gestagens or an intrauterine system with subsequent monitoring, and for atypical hyperplasia and endometrial cancer, removal of the uterus and appendages and further management by a gynecological oncologist are more often recommended. In all cases, weight normalization and blood sugar control are useful.
- Local estrogens for atrophy
- Hysteroscopic polyp removal
- Gestagens or intrauterine system for hyperplasia
- Surgical treatment for atypical hyperplasia and cancer
- Correction of anticoagulant therapy in consultation with a doctor
- Weight loss and diabetes control
