Common causes of postmenopausal bleeding
Post-Menopausal Bleeding (PMB) is vaginal bleeding that starts at least 12 months after your last period. Post-menopausal vaginal bleeding must always be investigated. In most cases no serious problem will be found, but there are times when the bleeding is the first symptom of serious disease, including cancer. Even when the bleeding is related to cancer, if it is diagnosed early, there is a very good chance that the disease can be cured.
In 90% of cases the condition causing the bleeding will not be serious. The two most common caused are:
- Atrophic vaginitis – which is when the lining of the vagina is inflamed due to the lower levels of the circulating hormone oestrogen
- Cervical and endometrial polyps – abnormal growth which left indefinitely have a small propensity to become cancerous
In around 10% of cases, PMB will be associated with endometrial (uterine) or cervical cancer, which are very serious conditions.
Investigation of PMB is based on a combination of imaging, such as ultrasound, and tissue sampling. In the investigation of PMB, the ultrasound measures the thickness of the lining of the uterus, endometrial thickness. This can show whether there is a likelihood of underlying cancer. Tissue sampling can be done with or without an anaesthetic. A Pipelle test samples the cells that line the uterus and can usually be done during the routine gynaecology examination. When this is possible a diagnosis will be made in about three quarters of all cases. Combined with ultrasound, a diagnosis will be made about 90% of the time.
In 10% of cases, the combination of a Pipelle test together with an ultrasound will not provide an answer. In these cases, a hysteroscopy with dilatation and curettage (D&C) may be recommended. Hysteroscopy uses a thin telescope that is inserted through the cervix into the uterus to visualise the lining of the uterus. D&C provides a tissue sample to send for pathological analysis. The hysteroscopy and D&C are generally performed as a day-case under general anaesthetic.
Treatment of postmenopausal bleeding
In most cases, there may be no investigations or management needed. A vaginal cream containing oestrogen may be recommended if the diagnosis is PMB due to thinning of the genital tissues. If further management is required, it will be individualised based on the findings and patient preference.