Important: This is intended as general information only. It may not apply to your specific situation. It is not a substitute for medical advice. If you have a question or concern, please raise it with me at your next appointment or contact me sooner if it's urgent.
Post Menopausal Bleeding
Post Menopausal Bleeding (PMB) is defined as any bleeding from the vagina after the menopause. Menopause is said to have occurred 12 months after your last period – so it is a diagnosis made in retrospect although, in reality, it is a process rather than a single event.
In most cases, PMB is nothing sinister. However, we always take it very seriously as, in a small proportion of cases, it can be sign of endometrial cancer (cancer of the lining of the uterus) or endometrial hyperplasia (an overgrowth of the lining of the uterus which can progress to endometrial cancer). Please don’t panic – most people with PMB do not have cancer! However, in the cases where PMB is a sign of cancer, it is usually an early sign. It’s important to make the diagnosis as early as we can because this makes treatment much easier and much more likely to be successful.
There are a few things that increase your risk of endometrial hyperplasia or cancer. These are
- Family history
- Obesity
- Type II diabetes
- Past history of anovulation (periods of time during which you did not ovulate regularly)
- Hormone replacement therapy
Investigating PMB
There are a few ways of investigating PMB. Essentially we are looking for the source of the bleeding (it may be coming from the vagina or cervix rather than the uterus) and looking closely at the lining of the uterus to work out whether there is any pathology there or not. Once we have worked out what is going on, we can then think about treatment.
Most women with PMB need the following:
- Pap smear – taking a pap smear allows us to look directly at the cervix and the smear itself looks at the cells of the cervix, looking for abnormalities that are, or may become, cancer
- Ultrasound – this allows us to look at the uterus and ovaries. In particular, we are interested in the thickness of the lining of the uterus (it should be quite thin after the menopause) and whether there are any polyps or other abnormalities.
- Hysteroscopy, dilatation and curettage – this is a minor operation, usually performed under general anaesthetic, in which a small camera is inserted through the vagina, though the cervix and into the uterus. This allows us to closely examine the vagina and cervix and look directly at the lining of the uterus. We can then take a small sample of the lining of the uterus, using a curette, which a pathologist will look at under a microscope. The pathologist is able to assess the cells of the lining of the uterus to determine whether they are abnormal.
After we have gone through the process of looking at the cervix and vagina and the lining of the uterus, if there is nothing sinister found, we consider this to be reassuring for about 12 months. If further bleeding occurs more than 12 months after these investigations, it is recommended that we reinvestigate to make sure that no pathology has developed in that time.
Treating PMB
Treatment is not always necessary. Many women will experience a single episode of bleeding which settles on its own. Providing we have had a look and determined that there is nothing serious causing the bleeding these women don’t require any further treatment.
If no serious underlying cause is found but the bleeding continues and is problematic, we can treat this by using hormones or, in some cases, surgery. If you find yourself in this situation, I will discuss the options with you in more detail.
If an underlying cause such as endometrial cancer or hyperplasia is found, obviously this will require treatment. If cancer is found, a hysterectomy is usually recommended and some women go on to require other treatment such as radiotherapy. If hyperplasia is found, treatment depends on the degree of severity and may range from short term hormone (progesterone) treatment to hysterectomy.
Summary
In summary, PMB does not usually indicate that there is something nasty going on. However, it can be an early sign of endometrial cancer so it should ALWAYS be taken seriously. Anyone with PMB should see their gynaecologist as soon as possible. Most of these women will find that they are, in fact, fine. If there is an underlying problem like cancer or hyperplasia, the sooner we make the diagnosis, the easier it is to treat.
