Causes of Postmenopausal Bleeding, Spotting and Cramping

Understanding Postmenopausal Bleeding

Post menopausal bleeding is bleeding that occurs one year or more after the last menstrual period. This can be difficult to define in women who do not have periods because they are taking hormones such as progesterone only contraception or HRT (hormone replacement therapy), so if you do have unexpected or unscheduled bleeding it is always advisable to get this checked out by your doctor or other healthcare professional,

We refer to spotting when the bleeding is literally just that – very light bleeding or spots of blood on the underwear or when wiping. We also include postcoital bleeding which is bleeding after intercourse. The bleeding or spotting sometimes occurs with cramping and pain – and sometimes not.

There are many causes of postmenopausal bleeding – most benign and not worrying – but a very small percentage of women will have a more sinister cause. This is why it is so important that any unscheduled bleeding is checked out, even if the bleeding is very light, spotting or dark old blood.

Determining the cause will lead to the correct way of treatment and management.

Vulval or vaginal atrophy

Description: With the drop of the hormone oestrogen, the vulva and vagina can become thin, delicate and more vascular. Skin may be prone to tearing and even spontaneous bleeding.

Symptoms: Vaginal bleeding and there may be other symptoms such as vaginal itching, irritation, burning, pain and discomfort and pain during intercourse. Externally on the vulva there may also be irritation.

Diagnosis: Atrophy is usually diagnosed by examination.

Treatment: Hormonal medications such as vaginal oestrogen cream, gel or pessaries.

Endometrial Atrophy

Description: The lining of uterus is called the endometrium and this loses its thickness after menopause because of the decrease in the hormone oestrogen.

Symptoms: Vaginal bleeding after menopause.

Diagnosis: Diagnosed commonly by ultrasound or by biopsy.

Treatment: Hormonal medications can be used to help to rebuild the endometrium.

Endometrial Hyperplasia

Description: Hormonal changes which cause the inner lining of the uterus to become thicker than normal. The concern is that endometrial hyperplasia may become ‘atypical’ and this can increase the risk of cancer of the womb lining.

Major risk factors include a body mass index (BMI over 40), genetic predisposition to cancer of the womb lining (so a family history of this may mean that you are at increased risk). Minor risk factors include a body mass index between 30 and 39, diabetes and a history of polycystic ovarian syndrome (PCOS).

The risk of endometrial hyperplasia can also increase if you take less than recommended doses of progestogen in relation to the oestrogen as part of your HRT.

Symptoms: Bleeding post menopause – this may be spotting, light or heavy unscheduled bleeding.

Diagnosis: Diagnosed by ultrasound and then biopsy, usually as part of a procedure called a hysteroscopy.

Treatment: Hormonal therapy, such as the Mirena or equivalent intrauterine system (‘coil’) in some. Surgical treatment such as hysterectomy may be needed if there are atypical cells in the womb lining – determined by biopsy when the conditions are chronic.

Polyps

Description: Polyps are usually benign growths (sometimes a little like ‘tags) on the endometrial lining (endometrial polyps), or in the canal of the cervix (endocervical polyps) – or sometimes on the surface of your cervix (cervical polyps).

Symptoms: Menstrual cramps and vaginal bleeding after menopause.

Diagnosis: Polyps are not often seen on ultrasound. Polyps are usually diagnosed by hysteroscopy where the cavity of the womb can be directly visualised. Examination of the cervix (like the examination you have when you go for a smear) allows your doctor to see cervical polyps – and you can sometimes see endocervical polyps at the entrance of the cervical canal.

Treatment: Remove is usually done through the hysteroscope – the common treatment for all these conditions is removal through minimally invasive surgery. The polyps can then be sent to the histology lab to make sure they are benign.

Polyps and Fibroids

Description: Benign growths muscular wall of the uterus that sit in the muscular wall, or protrude into the cavity of the uterus or protrude through the outside of the womb.

Symptoms: Heavy periods before the menopause, sometimes they cause bleeding after the menopause – particularly if they involve the cavity of the womb. If fibroids are very large, they can press on the bladder and bowel and cause pelvic pain.

Diagnosis: Imaging studies such as ultrasound. Fibroids in the cavity of the womb can be seen on hysteroscopy.

Treatment: Fibroids usually don’t need treatment unless they are causing symptoms. If they protrude into the cavity of the womb, they may be able to be removed during a hysteroscopy. Hormone treatments such as the Mirena coil can help lighten heavy bleeding caused by fibroids, and there are other hormonal treatments. If fibroids are very large the blood supply can be cut off, causing them to shrink – this is a procedure called embolization. Myomectomy is a procedure to remove the fibroids surgically and a hysterectomy may be needed – usually performed as a last resort.

Hormone Replacement Therapy (HRT)

Description: Some women have unscheduled bleeding on HRT – this is bleeding that would not be expected for the type of HRT that is being taken. For women using sequential HRT which is designed to give a regular withdrawal bleed this may be bleeding in between the withdrawal bleed including spotting. For women on a ‘no bleed’ continuous combined regime, unscheduled bleeding includes any bleeding. When HRT is started, it is common to have unscheduled bleeding in the first 3-6 months as your body adapts to the HRT. Bleeding after this – or bleeding after intercourse (post coital bleeding) or very heavy and frequent bleeding. There may be bleeding if the dose of oestrogen is high in relation to the progestogen, or if you miss doses of HRT.

Symptoms: Vaginal spotting and bleeding. .

Diagnosis: History, examination and ultrasound in the first instance. If the womb lining is thicker than expected, a biopsy of the womb lining may be needed.

Treatment: Changes may be needed in the type or dose of HRT.

Cancer

Most women who bleed after the menopause do NOT have cancer. However, it is important to get postmenopausal bleeding checked out so the more sinister causes can be excluded. See a doctor even if the bleeding is like old blood or very light spotting. If the cause does turn out to be cancer, the earlier its diagnosed, the better the chance of curative treatment for most types of cancer.

Endometrial Cancer

Description: Malignant change of cells of the womb lining. Endometrial cancer is the fourth most common cancer in women in the UK. Major risk factors include a body mass index (BMI over 40, genetic predisposition to cancer of the womb lining (so a family history of this may mean that you are at increased risk). Minor risk factors include a body mass index between 30 and 39, diabetes and a history of polycystic ovarian syndrome.

Symptoms: Post menopausal bleeding,

Diagnosis: Appropriate for invasive breast cancer with suspicious findings on imaging or in which imaging is planned.

Treatment: Treatment depends on the stage of cancer at diagnosis. Surgery is the treatment for early stage cancer. Other treatments may be needed for the less common more advanced stages.

Ovarian Cancer

Description: Malignant change of cells of the ovary. There are different types of ovarian cancer depending on the specific cells involved. In females in the UK, ovarian cancer is the 6th most common cancer.

Symptoms: Post menopausal bleeding, pelvic pain, persistent bloating, urgent need to pass urine or increased frequency of passing urine, changes in bowel habit and unexplained weight loss.

Diagnosis: CA125 blood test, ultrasound, further imaging may be needed such as CT or MRI.

Treatment: Depends on the stage of diagnosis but may include surgery and chemotherapy.

Cervical Cancer

Description: Malignant change of cells of the cervix (the neck of the womb.) Most cases develop in women aged between 25 and 45. Some cases develop in older and younger women.

Symptoms: Post menopausal bleeding, bleeding after sex. There may be pelvic pains and abnormal vaginal discharge.

Diagnosis: Examination of the cervix. Biopsy of the cervix at a procedure called colposcopy. Sometimes the cancer can be seen directly on examination. Other investigations include CT or MRI and other imaging.

Treatment: Surgery, some may need radiation or chemotherapy if the cancer has spread.

Vulval Cancer

Description: Malignant change of the skin of the vulva. This is a rare cancer – vulval cancer is not among the 20 most common cancers

Symptoms: Post menopausal bleeding,

Diagnosis: Skin changes of the vulva may be subtle. There may be itching or bleeding. Skin changes include redness, lumps and warty lumps or ulcers where the skin surface is broken, or there may be changing pigmented skin lesions (moles). Diagnosis includes a biopsy and other investigations including CT or MRI

Treatment: Surgery and other treatments may be required such as radiotherapy depending on how advanced it is.

Vaginal Cancer

Description: Malignant change of cells of the vagina. This type of cancer is rare meaning most GPs will not encounter a woman with the disease during their career.

Symptoms: Post menopausal bleeding, spotting and pelvic pain. There may be vaginal irritation and pain, plus changes to the vaginal tissue with ulceration and a mass may be present

Diagnosis: Examination, ultrasound, further imaging may be needed such as CT or MRI.

Treatment: Depends on the stage of diagnosis but includes surgery, radiotherapy and chemotherapy.

Less Common Other Causes of Postmenopausal Bleeding:

Infections

Description: Endometritis and cervicitis.

Symptoms: Post menopausal bleeding and cramping, a discharge can occur also which may be offensive.

Diagnosis:  A physical and pelvic examination where the doctor will look at the abdomen, uterus, and cervix for signs of tenderness and discharge. Microbiology swabs can be sent to the lab are needed for diagnosis.

Treatment: Antibiotics are needed, depending on the cause of the infection. These are usually given orally, but if the infection is severe, occasionally they may need to be intravenous.

Blood Thinners and Coagulopathies

Description: Administration of drugs which are anticoagulants may cause unscheduled vaginal bleeding.

Symptoms: Bleeding, bruising of the extremities.

Diagnosis: Blood tests to assess blood clotting. Other causes of postmenopausal bleeding will need to be excluded

Treatment: Adjusting medication dosages.

Diagnostic Approaches:

Ultrasound

For assessment of the endometrial thickness and the presence of structural pathology.

Endometrial Biopsy

Shows tissue samples in the determination of hyperplasia or malignancy.

Hysteroscopy

Provides a direct view or the uterine cavity and helps in easy identification of polyps or fibroid for removal. A very fine fibroptic scope is passes through the next of the womb. This is usually done in clinic or as a day case procedure under general anaesthesia.

Treatment Options

Treatment will very much depend on the cause of the bleeding.

Hormonal Therapy

Adjustments for HRT-related bleeding.

Surgical Interventions

Polypectomy or myomectomy for the polyps and fibroids.

Hysterectomy in cases of cancer or severe hyperplasia means that the removal of the uterus is required due to cancer or because the uterus has become too large and dangerous for the woman’s health.

Medication Adjustments

Specific application of this treatment in cases of bleeding associated with the use of anticoagulant agents.v

Conclusion

Any postmenopausal bleeding whether minor or severe should be reported to a doctor. In the majority of cases the cause will be something very simple and treatable but occasionally it is a sign of more serious disease. Once you know what is causing it your doctor can you help you access the right treatment

Reference:

https://www.cancerresearchuk.org/

https://cks.nice.org.uk/topics/gynaecological-cancers-recognition-referral/

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Frequently Asked Questions

You can find answers to some of the most frequently asked questions about our appointments here.

Please speak to your GP or gynaecologist before you come to us if:

• Your periods have become heavier or longer and/or if you are having spotting in between your periods or bleeding after sex.
• You start bleeding after having had no bleeding for over a year.
• You’re over the age of 55 and still experiencing bleeding, but aren’t taking hormones or HRT.

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