Women are said to be menopausal one year after they have their last period.
In most women, the menopause (see separate leaflet for the menopause and perimenopause) usually occurs around the age of 51 years, although in some women, periods may stop earlier or later and this can be normal for them.
Any bleeding after the menopause (after one year of no periods) is known as Post-Menopausal Bleeding (PMB) and should be taken seriously. Urgent medical advice should be sought, initially with your GP, so that appropriate tests can be carried out to reassure the woman that there is no underlying serious cause such as endometrial (womb) cancer. Women are often referred to the hospital as a two-week referral (Target) so that they can be seen quickly and reassured.
Causes of Postmenopausal Bleeding
Causes of PMB: Most women who have post-menopausal bleeding do not have cancer.
The vast majority of women bleed from a lack of the hormone, oestrogen, which drops after the menopause. This lack of oestrogen causes thinning of the vagina and of the lining of the womb (atrophic vaginitis or endometritis), leading to a loss of blood, which may range from just spotting to slightly more.
Women may notice traces of blood after sexual intercourse or using a dilator or sex toy as the skin can split causing both bleeding and pain (women often describe paper cuts after attempting sex). This is again due to thinning of the vagina. Lubricants and vaginal oestrogen may be recommended if appropriate.
Skin conditions like blood blisters, lichen sclerosus and eczema can cause spotting or trace of blood on underwear as these conditions can be itchy and sore and scratching thinned vulval skin can cause it to break down and bleed. See general vulval care measures leaflet.
Uterine or cervical polyps: Some women may have polyps (usually benign growths) in the lining of the womb (endometrium) called endometrial polyps or on the cervix (neck of the womb) that may cause them to bleed, sometimes enough to mimic a period.
Other causes could be medications that women are on such as hormone replacement therapy or blood thinning agents. Often, such bleeding occurs in the first year of starting these medications, but still need investigations to reassure and confirm there is nothing more serious causing the bleeding.
However, 1 out 10 women with PMB may have an underlying gynaecological cancer, which is why it is so important to seek medical advice soon.
Women who have bleeding any time after one year after their last period, especially after the age of 53 are at increased risk of being diagnosed with a cancer (womb, ovary, cervical, fallopian tube or endometrial (womb) cancer, the latter of which is the commonest in the western World).
Early endometrial cancer is usually treated very successfully by surgery; hence the importance of women being advised to seek help early once they have any abnormal bleeding.
Investigations for PMB
An ultrasound of the pelvis will be recommended, and this is usually a “trans-vaginal scan’ (TVS). This is when the sonographer places a probe into the vagina. This often gives clearer images of the pelvic organs. It is not painful, and women are always asked for their consent for this procedure. A friend or relative may be with the woman or a chaperone from the department can be requested, if the woman feels more comfortable.
An ultrasound will help to give further information to help reach a diagnosis, for example a thickened lining may be noted or polyps or ovarian cysts.
If the endometrial lining is very thin as expected in the menopause (<4 mm) and the woman has had a first-time bleed with no other risk factors, she may be observed without need for a biopsy. This is because, in the presence of a atrophic or thin womb lining, the risk of womb cancer is extremely low (0.6%). However, individualised management is very important, considering the circumstances, history and risk factors.
Pipelle Endometrial Biopsy
A small sample may be taken in the clinic (pipelle) to sample the lining of the womb. In most cases, this is a straightforward outpatient procedure with minimal discomfort. Any tissue obtained is sent for analysis.
For detailed information on having a hysteroscopy, please see separate leaflet.
Some women may need to have a hysteroscopy, especially if the scan has suggested a thickened lining (more than 4-5mm). A hysteroscopy involves using a camera with a small telescope to look inside the womb. If possible, the endometrial lining may be sampled for analysis or small polyps may be removed. This is generally a safe and simple procedure and can be done as an outpatient procedure, taking about 20 minutes.
However, some women may not be suitable for outpatient hysteroscopy for several reasons, and they may need to have the procedure performed under a light general anaesthetic. These women will normally be able to return home, accompanied by a responsible adult, the same day.
Outcome of Investigations
Depending upon the results of the ultrasound scan or hysteroscopy, most women will be reassured and discharged with advice, with results of any biopsy taken communicated within two weeks.
Magnetic Resonance Imaging (MRI) or CT scan
However, some women may be asked to return for an MRI or CT of the pelvis. The images will aid in diagnosis and planning treatment.
At any stage during the investigations, it is likely some blood tests will be requested to help with planning management.
Multi-Disciplinary Team Meetings (MDT)
Once all the investigations have been completed, results will be reviewed and if there is a diagnosis of a gynaecological cancer, this will be discussed and best management planned at a meeting attended by gynaecologists, specialist nurses, a histo-pathologist and a radiologist.
A follow-up appointment will be made for the woman after this MDT meeting, where she will be informed of, and included in, any decisions regarding possible treatments.
This will depend upon the underlying condition. The treatment for early endometrial cancer is usually a hysterectomy. This involves removal of the womb, fallopian tubes and ovaries. It can be done by keyhole surgery (laparoscopic hysterectomy). It has been shown that women who have keyhole surgery generally do better than those who undergo the traditional method via a large cut in the abdomen.
Most women however, after having appropriate investigations and treatment will be able to be reassured and discharged.
Dr Nitu Bajekal FRCOG Dip IBLM
Consultant Gynaecologist and Women’s Health Expert
Lifestyle Medicine Physician