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You are done and dusted with menopause, your symptoms are well-controlled, and your periods seem like ancient history. But you wake up one morning and find yourself bleeding after ten years of menopause. Is it normal? Did you hurt yourself? Are your periods back? Your brain starts getting bombarded with all sorts of thoughts, but amidst all these questions, the most important one is, is bleeding after menopause always cancer, and should you be concerned?

It is understandable to worry about menopause bleeding, especially when your periods are long gone. The good news, according to a research analysis, is that postmenopausal bleed is most likely secondary to a noncancerous condition, such as uterine fibroids, polyps, or vaginal atrophy. [1] That said, experts reinforce the idea of getting a scheduled appointment to rule out more sinister causes, like cancer.

Read Also About : Nutrition And Menopause

Even though most post menopause bleeding incidents are not related to cancer, it is one of the presenting complaints in up to 90 percent of women with underlying endometrial cancer (cancer of the uterus lining). [2] Read on to explore menopause bleeding, the potential causes, investigations, and treatment options available to manage it.

Any incident of vaginal bleeding during or following menopause is labeled as menopausal bleeding. Different women may experience this bleeding differently, though the following presentations have been commonly observed:

  • Bleeding mimicking a menstrual period
  • Passing a small amount of blood, also known as spotting
  • Blood appearing on toilet paper after using the toilet
  • Passage of blood clots with other bleeding
  • Pink vaginal discharge
  • Bleed following a vaginal intercourse
  • A heavier flow than what would normally be expected during menstrual periods
  • Brown vaginal discharge

In addition to experiencing bleeding and cramping after menopause, some women may also notice the following symptoms:

  • Fever
  • Abdominal pain
  • Headaches
  • Chills
  • Changes in bowel and/or bladder function
  • Dizziness

It is imperative to seek help for postmenopausal bleeding regardless of the frequency or quantity of blood flow. Even a one-off instance of postmenopausal bleed warrants an urgent discussion with a healthcare provider to rule out sinister causes, like cancer.

Is bleeding after menopause always cancer? Not necessarily. So, what are the other potential causes to explore?

A variety of issues can cause you to bleed after menopause, such as an active infection, ongoing hormone therapy, or the use of certain medications like blood thinners. Some of the most common causes include the following:

Atrophic Vaginitis

Atrophic vaginitis refers to a condition where the vaginal skin becomes delicate, thin, and prone to reputing and bleeding. This phenomenon is widespread in postmenopausal women as their estrogen levels begin to decline. [3]

Estrogen is a key sexual hormone that supports the vaginal health and skin integrity, and as its levels plummet after menopause, the vaginal skin thins and gets damaged and inflamed very easily. The damage can extend to the womb, causing bleeding to sometimes occur from the inside.

Finding the site of bleed is not always possible in a postmenopausal woman who is actively bleeding. Hence, atrophic vaginitis remains a diagnosis of exclusion and is considered when a doctor has ruled out all other possibilities.

Endometrial hyperplasia

Endometrial hyperplasia refers to a condition in which the lining of the uterus grows faster than its normal pace. This fast-paced, uncontrolled growth causes the lining to thicken and bleed occasionally. Endometrial hyperplasia is typically benign and has little risk of becoming malignant.

However, in some cases, the hyperplastic cells may transform and become abnormal, increasing the risk of cancer.

Uterine Polyps

Polyps are abnormal growths that occur when the uterus lining thickens. As the peristaltic movement happens in the uterus, it pulls on the thickened area, causing the skin to outpouch in the form of a polyp.

Polyps are of different sizes, and despite being generally benign, they can sometimes bleed. [4] Their occurrence in postmenopausal women is quite common due to their higher tendency to develop endometrial hyperplasia.

Ovarian Cysts

The ovary can develop benign cysts that may bleed from time to time in postmenopausal women. These cysts are fortunately detectable through a pelvic ultrasound and can be treated.

Uterine Cancer

Also known as endometrial cancer, uterine cancer is the most common type of cancer presenting as postmenopausal bleeding. Even a one-off bleed following menopause is enough to indicate this cancer, but it typically presents as repeated bleeding episodes.

Fortunately, most cases of uterine cancers are caught early on as they immediately cause bleeding or spotting during menopause. Treatment is also available depending on how early it is seen and whether the cancer is localized or spread to other body parts.

Fibroids

These uterine muscle overgrowths can be another cause of postmenopausal bleeding. Fibroids are typically asymptomatic and may go unnoticed for years but can bleed after menopause, especially if you are on hormone replacement therapy. Other accompanying symptoms that point towards fibroids as a potential cause of postmenopausal bleed include lower back pain, pelvic pressure, and constipation. 

Cervical Cancer

Cancer of the cervix, the part of the female reproductive system immediately above the vagina, is one of the most common types of cancers in females and can often present as postmenopausal bleeding. [5] It is possible to catch it during the early stages through regular smear tests, and the cure rate is generally high.

Cancer of the Ovaries

Certain types of ovarian cancers can cause bleeding in postmenopausal women. These cancers often secrete estrogen, which causes destabilization of the delicate endometrium and causes it to bleed. If caught early, ovarian cancer is treatable, but once it has progressed, it becomes more difficult to cure.

As mentioned above, bleeding after menopause is not always cancer but warrants an in-depth assessment to rule it out. Moreover, certain risk factors may also predispose you to cancer, such as:

  • Your age bracket (cancer is most common in ages 60 to 70)
  • Late menopause (typically after 55 years)
  • Early menarche (before 12 years) [6]
  • No history of childbirth
  • A history of endometrial hyperplasia
  • Family history of uterine, ovarian, or colon cancer
  • Taking estrogen therapy
  • A history of irregular menstrual cycle
  • Obesity
  • Taking certain drugs (such as tamoxifen)
  • Family history of Lynch syndrome
  • Radiation exposure to the pelvic area

Postmenopausal bleeding can present variably, from a pinkish-brown vaginal discharge to a heavy flow, with or without. Regardless of the spectrum of symptoms, you must always get in touch with a doctor to get to the bottom of this and find a potential cause.

Investigations for bleeding and cramping after menopause typically begin with an in-depth conversation, either in-person or virtual. Some questions that your doctor may ask as a part of this discussion include the following:

  • When did you have menopause? The longer it has been, the more testing you may need to rule out any concerning causes
  • How is your health In general? Are you facing any other issues?
  • Are there any other relevant medical conditions you suffer from?
  • Are you on any new medications, such as blood thinners, that may cause vaginal bleeding as a side effect?

Following a detailed history-taking session, a doctor may perform a pelvic exam to look at the vagina and cervix, assess the size of the uterus, and rule out any possible causes. From here, the choice of investigation will depend on the individual history and the severity of ongoing bleeding. Following are some investigations commonly requested as a part of the screening process:

Endometrial Biopsy

This process involves inserting a thin tube into the uterus to take a small sample of the cell lining. The lab then assesses this sample for any cancerous cell mutations.

Ultrasound

This painless imaging technique relies on sound waves to check the thickness of the uterine lining. Depending on the clinical situation, an ultrasound may involve a non-invasive external device or a wand inserted into the vagina. Ultrasounds can easily pick up endometrial hyperplasia, which alerts health professionals about the possibility of cancer. However, it is essential to reiterate that not all cases of endometrial hyperplasia are cancerous.

If the ultrasound shows a thin endometrial lining (usually less than 4 millimeters) with a history of first-time bleeding, watchful waiting is usually proposed before moving to more invasive testing. This is because the presence of a thin uterus lining significantly reduces the likelihood of uterine cancer, sometimes up to only 0.6%. However, circumstances may vary based on individual history and associated co-morbidities.

Hysteroscopy

This test involves the insertion of an instrument with a camera and light at one end into the uterus to examine the inside and look for any potential postmenopausal bleeding cause.

Dilatation and Curettage

As part of this process, a trained healthcare professional dilates the cervix using an instrument. A small blade is then used to scrape tissue from the uterine lining, which can then be examined in the lab for any malignant transformations.

Sonohysterography

Also known as saline infusion ultrasound, this procedure involves filling the uterus with saline, which improves visualization. 

Your doctor will review the results once all investigations have been completed and reports are available. If there is a suspicion of gynecological cancer, a multidisciplinary team meeting should be arranged involving gynecologists, radiologists, histopathologists, and specialist nurses. These meetings aim to consider all aspects of the current situation and formulate an appropriate plan to treat the underlying cancer from all ends.

A follow-up appointment typically follows this team meeting, during which you will be informed of the decisions regarding the possible treatments.

Postmenopausal bleeding has various treatments depending on the cause. These treatments are broadly classified into two categories: medications and surgery.

Medical options for post menopausal bleeding include:

Antibiotics

Antibiotics can be the treatment of choice where postmenopausal bleeding is likely due to a urogenital infection, such as vaginitis or cystitis.

Estrogen Therapy

Estrogen is given to control postmenopausal bleeding secondary to endometrial and vaginal atrophy. It is commonly available in the following forms:

  • Pills to be taken orally
  • Creams to apply inside the vagina through an applicator
  • An estrogen-secreting vaginal ring to insert inside the vagina
  • Tablets to insert inside the vagina through an applicator

Progestin Therapy

This therapy involves the use of a synthetic variant of the progesterone hormone to manage endometrial hyperplasia in the form of a vaginal cream, pill, or an intrauterine device.

Chemotherapy

Depending on the type and extent of cancer-causing postmenopausal bleeding, a healthcare physician may offer different cycles of chemotherapy medications.

Surgical options for postmenopausal bleeding include:

Hysteroscopy

This procedure not only allows healthcare providers to diagnose the cause of uterine bleeding, such as polyps and other growths but also remove them at the same time.

Dilatation and Curettage

Also known as D&C, this process involves the use of hysteroscopy to manage certain types of endometrial hyperplasia as a potential cause of postmenopausal bleeding.

Hysterectomy

This surgical procedure involves removing the cervix and uterus to make you cancer-free. There are different approaches to hysterectomy to explore based on individual cases. It is often coupled with chemotherapy or radiotherapy for better clinical outcomes. [7]

Prompt medical treatment may be required following hysterectomy to identify and manage any complications and associated issues and improve outcomes.  

Endometrial Ablation

If endometrial hyperplasia or abnormally thickened uterus lining is the cause of your postmenopausal bleeding, a doctor may consider endometrial ablation as a possible treatment plan. The process involves removing the thickened part to reduce bleeding or stop it altogether. However, it is safe to proceed with this procedure only if the biopsy has ruled out malignancy.

Women are well known to prioritize their families and often put their health second. However, it is important to look after your health if you wish to care for your loved ones.

Remember, going through menopause does not make your reproductive organs any less critical. While every bleeding after menopause is not always cancer, the risk certainly increases as you age. So, always pay attention to your body and alert your doctor to any abnormal changes, including postmenopausal bleeding, as soon as you can.

[1] Newell S, Overton C. Postmenopausal bleeding should be referred urgently. The Practitioner. 2012 Mar 1;256(1749):13-6.

[2] Sung S, Abramovitz A. Postmenopausal bleeding. InStatPearls [Internet] 2022 Sep 18. StatPearls Publishing.

[3] Flores SA, Hall CA. Atrophic vaginitis.

[4] Nijkang NP, Anderson L, Markham R, Manconi F. Endometrial polyps: Pathogenesis, sequelae and treatment. SAGE open medicine. 2019 Apr;7:2050312119848247.

[5] Sebastian A, Neerudu SR, Rebekah G, Varghese L, Regi A, Thomas A, Chandy RG, Peedicayil A. Risk factors for endometrial carcinoma in women with postmenopausal bleeding. The Journal of Obstetrics and Gynecology of India. 2021 Aug;71:417-23.

[6] Gong TT, Wang YL, Ma XX. Age at menarche and endometrial cancer risk: a dose-response meta-analysis of prospective studies. Scientific reports. 2015 Sep 11;5(1):14051.

[7] Kokka F, Bryant A, Olaitan A, Brockbank E, Powell M, Oram D. Hysterectomy with radiotherapy or chemotherapy or both for women with locally advanced cervical cancer. Cochrane Database of Systematic Reviews. 2022(8).

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