Any bleeding after menopause is abnormal and should be reported to a gynecologist. The most important responsibility of the gynecologist in such a case is to rule out uterine cancer. Therefore, all women who have bleeding after reaching menopause should undergo evaluation.
Cause of Postmenopausal Bleeding:
Polyps: A polyp is an abnormal growth of tissue that develops from the mucous membrane of uterus (endometrium). It is either attached with the help of a stalk (pedunculated) or is directly attached (sessile) to the membrane. It causes abnormal or heavy bleeding. The further risk is growing on the cervix or inside the cervical canal. These polyps may cause bleeding after sex.
Thinning of the Endometrium Membrane: Thinning of the Endometrium is common due to low estrogen levels, especially after menopause. Such a condition is known as endometrial atrophy. Thinning of lining. In few cases the lining causes abnormal bleeding due to tissue breakdown.
Endometrial Hyperplasia: in this condition, the cells increase leading to thickening of uterus lining. In few cases the lining can have atypical changes (atypical hyperplasia) and these can cause cancer of the uterus. Endometrial Hyperplasia is often due to excess estrogenic stimulation of the endometruim in the absence of progesterone. The source of excess oestrogen can be from an ovarian tumor or simply from the fat cells that convert the androgens into estrogen. Hence, obese women with such bleeding may have higher chances of endometrial cancer. Treatment and diagnosis of endometrial hyperplasia can prevent many cases of endometrial cancer.
Cancer of Endometrium: Incidence of this cancer is on the rise. The most common symptom of endometrial cancer is bleeding after menopause. When diagnosed early, most cases of endometrial cancer can be treated successfully. If a woman has the triad of diabetes, high blood pressure and obesity, she is especially at risk of developing uterine cancer.
Postmenopausal Bleeding Risks Factors:
- Advancing age
- Early menarche and late menopause
- Infertility and treatment for infertility
- History of delayed cycles
- Prolonged usage of hormones (oestrogen)
- Polycystic ovarian syndrome (PCOS)
- Treatment with Tamoxifene, a drug used for breast cancer
Postmenopausal Bleeding Diagnosis:
1. Ultrasound: To look for any thickness of endometrium or ovarian cysts. Any thickness of more than 5 min in a postmenopausal woman warrants further investigations.
2. Hysteroscopy, Biopsy and D&C: This is the gold standard in diagnosis. A narrow, lighted tube attached with a camera called hysteroscopy is inserted through vagina. It allows better visibility vagina. It allows better visibility of the uterus; tissue for biopsy is taken and sent to the lab for further assessment. If only D&C is done without hysteroscopy then there is a chance that intrauterine pathology may be missed especially polyps.
Postmenopausal Bleeding Treatment:
• Noncancerous conditions can be managed conservatively by removing polyps if present and further management is usually done with medicines.
• Simple hyperplasia can be managed with medical therapy. Complex hyperplasia with atypia has higher chances of leading to endometrial cancer and is best treated by performing hysterectomy. Laparoscopic hysterectomy or non-descent vaginal hysterectomy is the method of choice, as these two will cause minimal pain and quick recovery, as many patients with this problem are also obese.
• Endometrial cancer is treated with surgery (hysterectomy along with removal of pelvic and Para aortic lymph nodes). If the disease is detected early then cure rates are good. Some advance cases may require radiotherapy and chemotherapy. Follow up after surgery is as essential as the surgery itself. Thus, all women operated for uterine (endometrial) cancer should also come for follow up check-ups.