Associated Women's Health Specialists  
     
     

Menopausal Bleeding

Around menopause, a woman's menstrual cycles may become less regular. After menopause, you should not have any bleeding. Any bleeding after menopause should be checked by a doctor. Bleeding after menopause may be a sign of cancer. This pamphlet will explain:

  • The causes of bleeding
  • How it is diagnosed
  • How it is treated

If you have any bleeding after menopause, see your doctor. The earlier the cause of bleeding is found, the better it can be treated.

Bleeding Around and After Menopause

Menopause is the time in a woman's life when she stops having menstrual periods (see box). It occurs in most women around age 52 years. However, the timing varies among women. At menopause, the ovaries produce less of the hormone estrogen. Less progesterone is produced as well.

The years leading up to this point are called perimenopause. This means "around menopause." This phase can last for up to 10 years.

Changes in hormone levels can affect ovulation and change bleeding patterns as a woman nears menopause. Your periods may become shorter or longer. Blood flow may get heavier or lighter. You may begin to skip periods. When a woman has not had a period for 1 year, she is postmenopausal.

The Menstrual Cycle

The menstrual period begins with the first day of the bleeding of one period and ends with the first day of the next period. An average menstrual cycle lasts about 21–35 days.

During the menstrual cycle, estrogen and progesterone—two hormones made by the ovaries—cause changes in the lining of the uterus.

On about day 14 of your cycle, an egg is released from one of the ovaries. This is called ovulation. The egg moves into one of the fallopian tubes connected to the uterus where it can be fertilized by a sperm. If the egg is not fertilized, pregnancy does not occur.

The levels of hormones then decrease. This signals the uterus to shed its lining. This shedding is your monthly period. It marks the start of a new cycle.

Some months an egg may be released, and some months it may not. If an egg is not released, the ovaries will not produce enough progesterone to signal the uterus to completely shed its lining. Instead, they will just keep making estrogen. Estrogen makes the lining of the uterus (endometrium) thicker. When it gets too thick, you may have irregular bleeding or spotting that may last longer than your usual period. This occurs when the lining is not fully shed.

Causes of Abnormal Bleeding

Although periods tend to be less regular around menopause, irregular bleeding can be a sign of problems. Any bleeding after menopause should be checked by a doctor. You also should be checked if you are older than 55 years and still have menstrual periods.

In postmenopausal women, bleeding is most often caused by:

  • A thinning of the uterine lining (endometrial atrophy)
  • Hormone therapy
  • Polyps (noncancerous growths that develop from tissue such as that lining the inside of the uterus)
  • Endometrial hyperplasia (a condition in which the lining of the uterus grows too much; if left untreated for a long time, it may lead to cancer)
  • Endometrial cancer (cancer of the lining of the uterus)
In postmenopausal women with uterine bleeding, 1 in 8 will receive a diagnosis of endometrial cancer. Women are at increased risk of this type of cancer if they have certain risk factors (see box), but it also can occur with no risk factors. Bleeding can be an early sign of this type of cancer. When this type of cancer is found early, it often can be treated with success.

Other causes of bleeding in menopausal women include:

  • Infection of the uterus or cervix
  • Chronic medical conditions (for instance, thyroid problems)
  • Use of some medications
  • Other cancers
Hormone Therapy

Some women may choose to take the hormones estrogen and progesterone after menopause to relieve hot flushes and vaginal dryness and to protect against osteoporosis. Taking estrogen alone increases a woman's risk of uterine cancer. Taking progesterone with estrogen decreases the risk of uterine cancer, but it can cause bleeding in menopausal women. Most women take both estrogen and progesterone to protect the uterus.

Risks for Endometrial Cancer

A woman is at an increased risk of endometrial cancer if she:

  • Is obese
  • Does not ovulate regularly and often misses periods
  • Has a late menopause
  • Has polycystic ovary syndrome
  • Has had endometrial hyperplasia that has not been treated
  • Has had cancer of the ovary, breast, or colon
  • Has a close family member with uterine cancer
More than one half of women have bleeding or spotting after they start hormone therapy (HT). The pattern of the bleeding depends on how HT is taken. When you take estrogen and progesterone daily, the bleeding lessens with time. In most women, it stops within 6 months.

Whether a woman gets this side effect depends in part on:

  • The amount and type of HT she takes
  • How soon after menopause she starts HT
Hormone therapy can be given in many ways. Your doctor may prescribe HT that is taken:
  • Orally (by mouth)
  • Vaginally (cream, pill, or ring)
  • Transdermally (through the skin)
There are 2 main types of HT:
  1. Continuous-combined therapy: Estrogen and a progestin are taken every day. It is common to have irregular bleeding the first few months.
  2. Cyclic therapy: Estrogen is taken through the cycle and progestin is added for certain days in the month. The exact times may vary. During the time when estrogen is taken alone, you may have some bleeding.
A woman also is more likely to have bleeding with HT if it's been less than 3 years since menopause when she starts the therapy. A woman on HT should be concerned if:
  • She has been on HT for 6 months or more and still has bleeding
  • She has not been bleeding and suddenly begins to bleed again
Diagnosis

To diagnose abnormal bleeding, your doctor will review your personal and family health history. You will have a physical exam and may have blood tests. Other tests may be needed based on your symptoms:

  • Endometrial biopsy: Using a catheter (tube), a small amount of tissue is gently scraped from the lining of the uterus. It is then looked at under a microscope.
  • Ultrasonography: Sound waves are used to create a picture of the pelvic organs. The device may be placed on the abdomen or in the vagina.
  • Sonohysterography: A small amount of fluid is injected into the uterus, and sound waves are used to create a picture of the pelvic organs to detect abnormal changes in the uterus.
  • Hysteroscopy: A thin device is inserted through the vagina and cervix to view the inside of the uterus.
  • Dilation and curettage (D&C): Procedure in which the opening of the cervix is widened. Tissue is then gently scraped or suctioned from the lining of the uterus. It is examined under a microscope.
These tests can be done in the doctor's office or in an out-patient surgery center with pain relief.

Treatment

Treatment for postmenopausal bleeding will depend on the problem and its cause. If the endometrium is thinning, estrogen may be given. If the endometrium is growing too much, progesterone may be used. It may take a few months for HT to control your bleeding. Your doctor will check your progress.

If there are growths (such as polyps) that are causing the bleeding, you may have to have surgery to remove them. This may be done with hysteroscopy and D&C. If you have endometrial hyperplasia, it may be treated with medication or surgery. If you have endometrial cancer, surgery (often hysterectomy) is needed in most cases. Discuss your options with your doctor.

Finally...

If you have any bleeding after menopause, see your doctor. Postmenopausal bleeding has a number of causes, including cancer. The earlier the cause of postmenopausal bleeding is found, the better it can be treated. If bleeding comes back after treatment, your doctor needs to know right away.

Estrogen: A female hormone produced in the ovaries.

Fallopian Tubes: Tubes through which an egg travels from the ovary to the uterus.

Hormone Therapy: Treatment in which estrogen, and often progestin, is taken to help some of the symptoms caused by the low levels of these hormones.

Menopause: The process in a woman's life when ovaries stop functioning and menstruation stops.

Osteoporosis: A condition in which the bones become so fragile that they break more easily.

Ovaries: Two glands, located on either side of the uterus, that contain the eggs released at ovulation and that produce hormones.

Ovulation: The release of an egg from one of the ovaries.

Polycystic Ovary Syndrome (PCOS): A condition in which increased androgen levels occur and eggs are not released from the ovaries.

Progesterone: A female hormone that is produced in the ovaries and that prepares the lining of the uterus for pregnancy.

Progestin: A synthetic form of progesterone that is similar to the hormone produced naturally by the body.

Uterus: A muscular organ located the female pelvis that contains and nourishes the developing fetus during pregnancy.