Postmenopausal bleeding: What it means and when to seek help

While postmenopausal bleeding (PMB) can be worrying, it is not always a sign of something serious. However, because in some cases it may indicate an underlying condition that needs medical attention, it is always important to get it checked promptly.

In this article, consultant obstetrician and gynaecologist Mrs Anjali Ahluwalia explains the possible causes of postmenopausal bleeding, what investigations are typically carried out, and how it can be managed.

What is postmenopausal bleeding?

Menopause is defined as the point when a woman has not had a period for 12 consecutive months, marking the end of natural reproductive cycles. Any vaginal bleeding that happens after this time is considered postmenopausal bleeding.

The bleeding may appear as light spotting or may resemble a normal period. Regardless of how heavy or light it is, any bleeding after menopause should be discussed with a doctor.

What causes postmenopausal bleeding?

There are several possible causes of postmenopausal bleeding, ranging from harmless to more serious conditions. The most common include:

1. Vaginal or endometrial atrophy

After the menopause, the body produces less oestrogen, which can cause the lining of the vagina and womb to become thin and fragile. This may lead to light bleeding or spotting, especially after intercourse.

2. Hormone replacement therapy (HRT)

Some forms of HRT can cause irregular bleeding, particularly in the first few months after starting treatment. This is usually harmless but should still be reviewed if it continues beyond six months.

3. Endometrial (womb lining) polyps

Polyps are small, benign growths that can develop on the lining of the uterus and cause light or irregular bleeding. These are usually non-cancerous but can occasionally require removal.

4. Endometrial hyperplasia

This condition refers to a thickening of the womb lining, often due to excess oestrogen. It is not cancer, but in some cases it can develop into endometrial cancer if left untreated.

5. Endometrial cancer

Although less common, postmenopausal bleeding can sometimes be the first sign of cancer of the womb lining. For this reason, any episode of bleeding after the menopause should always be assessed promptly.

How is postmenopausal bleeding investigated?

Your doctor will begin by taking a detailed medical history and may perform an examination. The next step is usually a transvaginal ultrasound scan, which allows the doctor to measure the thickness of the womb lining.

If the lining appears thickened, further tests such as an endometrial biopsy or hysteroscopy (a camera examination of the womb) may be recommended. These investigations help identify the underlying cause and ensure that any serious conditions are ruled out.

What are the treatment options?

Treatment depends on the underlying cause:

• Atrophic changes are often treated with topical oestrogen creams or pessaries.
• Polyps can be removed during a hysteroscopy.
• Endometrial hyperplasia may be managed with hormone therapy or minor surgery.
• If endometrial cancer is diagnosed, treatment is guided by a gynaecological oncology specialist and may involve surgery, radiotherapy, or a combination of both.

While postmenopausal bleeding can understandably cause concern, it is important to remember that many cases are due to benign conditions. Nevertheless, any vaginal bleeding after the menopause should be assessed by a doctor to rule out more serious causes and allow for timely and effective treatment.