Any vaginal bleeding that occurs 12 months or more after your final menstrual period is considered postmenopausal bleeding. While unsettling, it is not always a sign of cancer. This bleeding is never normal and requires prompt medical evaluation, but the vast majority of cases are caused by treatable, non-cancerous conditions. Seeing a doctor is a necessary step to determine the specific cause and ensure proper management.
Common Causes of Postmenopausal Bleeding
The most frequent cause of bleeding after menopause is atrophy, a condition where the tissues of the endometrium (uterine lining) and vagina become thin, dry, and inflamed. This happens due to the natural decline in estrogen levels that accompanies menopause. Without sufficient estrogen, these tissues can become fragile and more susceptible to injury and spontaneous bleeding.
Benign growths are another common source of bleeding. Uterine polyps, which are small growths attached to the inner wall of the uterus, can cause spotting or bleeding. Similarly, fibroids, which are non-cancerous tumors that grow from the muscle tissue of the uterus, can also lead to bleeding, although they are a less frequent cause after menopause compared to polyps. Both of these conditions can often be managed.
A condition known as endometrial hyperplasia is another potential cause. This involves the uterine lining becoming abnormally thick, which can trigger bleeding. Hyperplasia results from an imbalance of hormones, specifically too much estrogen without enough progesterone to counteract it. While hyperplasia itself is not cancer, certain types are considered precancerous as the abnormal cells can develop into cancer if untreated.
Certain medications, particularly hormone replacement therapy (HRT), can also induce bleeding. Some forms of HRT are designed to cause predictable, cyclical bleeding like a period. Unexpected or irregular bleeding while on HRT should still be evaluated by a physician. Though less common, infections of the uterus or cervix can also be a source of bleeding.
Evaluating the Risk of Cancer
Although most instances of postmenopausal bleeding result from benign conditions, it stands as the most common symptom of endometrial cancer, which is cancer of the uterine lining. Approximately 10% of individuals who experience postmenopausal bleeding are diagnosed with endometrial cancer. Early detection is directly linked to more successful treatment outcomes.
Several factors increase the risk of developing endometrial cancer. Obesity is a significant risk factor because fat tissue can produce estrogen, leading to higher levels of the hormone, which encourages the growth of the uterine lining. Conditions like diabetes and high blood pressure (hypertension) are also associated with an elevated risk.
Reproductive and family history also play a part. Women who began menstruating before age 12, entered menopause late, or have never given birth may have a higher risk due to a longer lifetime exposure to estrogen. A personal history of polycystic ovary syndrome (PCOS) or a family history of certain cancers, such as Lynch syndrome, also increases the risk.
The Medical Evaluation Process
The evaluation begins with a comprehensive medical history and a physical exam. This includes a pelvic exam to check the vulva, vagina, and cervix for any abnormalities, such as signs of atrophy, lesions, or growths. A Pap test may also be performed during this exam to screen for irregular cells on the cervix.
A transvaginal ultrasound is a common next step. For this procedure, a small ultrasound probe is inserted into the vagina to get a clear picture of the reproductive organs. This allows the doctor to measure the thickness of the uterine lining, known as the endometrial stripe. A very thin lining suggests atrophy is the cause, while a thickened lining may require further investigation.
To get a definitive diagnosis, an endometrial biopsy is often performed. This procedure involves taking a small tissue sample from the lining of the uterus. The sample is then sent to a laboratory to be examined under a microscope for any abnormal or cancerous cells. The procedure can be done in the doctor’s office.
In some situations, a procedure called a hysteroscopy may be recommended. During a hysteroscopy, a thin, lighted tube with a camera on the end is inserted through the vagina and cervix into the uterus. This allows the doctor to look directly at the uterine lining to identify issues like polyps or fibroids, which can often be removed during the same procedure.