Postmenopausal Bleeding

     Menopause refers to the stage when the ovaries cease producing female hormones, leading to the cessation of menstruation. It is diagnosed after 12 consecutive months of amenorrhea or through blood tests indicating elevated FSH levels and decreased estradiol (E2).

Postmenopausal Bleeding

     Menopause typically occurs between the ages of 45–55, with an average onset at 51. Any abnormal bleeding after menopause warrants prompt evaluation to determine the cause and ensure appropriate care. The incidence of postmenopausal bleeding is approximately 4–11%.

Causes of Abnormal Bleeding in Postmenopausal Women

• Structural abnormalities (≈60%): Endometrial polyps, atrophic endometrium, uterine fibroids (leiomyoma), and adenomyosis.
• Endometrial hyperplasia and carcinoma: Occurs in about 6–9% of cases.
• Medications: Includes hormone therapy, anticoagulants, herbal supplements, and other drugs.
• Other causes: Infections (e.g., endometritis), adjacent organ inflammation (e.g., diverticulitis).

Diagnosis of Postmenopausal Bleeding

The primary goal is to rule out endometrial cancer. This involves medical history, physical examination, ultrasound imaging, and endometrial biopsy. Risk factors for endometrial cancer include:

• Age (1.4% prevalence in women aged 50–70)
• Unopposed estrogen therapy
• Use of tamoxifen
• Late menopause (>55 years)
• Nulliparity
• Polycystic ovary syndrome (PCOS)
• Obesity
• Diabetes
• Genetic syndromes (e.g., Lynch syndrome, Cowden syndrome)

Biopsy Methods

• Endometrial aspiration
• Fractional curettage
• Hysteroscopic-guided biopsy

Treatment of Abnormal Bleeding in Postmenopausal Women

Treatment depends on the underlying cause. The key objective is to distinguish between benign and malignant conditions.

• High-risk for endometrial cancer: Perform endometrial biopsy and treat according to histopathology.
• Low-risk with endometrial thickness ≥5 mm: Biopsy and manage accordingly.
• Low-risk with thickness <5 mm: Monitor symptoms closely.

Specific Conditions

• Endometrial polyp: Surgical removal, especially if cancer risk factors are present.
• Endometrial hyperplasia:
  • With atypia: Hysterectomy is recommended.
  • Without atypia: Medical treatment with progestins or hormone-releasing IUDs; surgery if unresponsive.
  • Suspected cancer: Consider hysterectomy with oophorectomy.

• Bleeding from hormone replacement therapy: If bleeding persists beyond 6 months, perform a biopsy and treat based on the pathology.
• Atrophic endometrium: Estrogen therapy or symptom monitoring.
• Cancer: Treatment is based on the site and stage of origin.

Conclusion

     Abnormal uterine bleeding can occur at any life stage, including adolescence, reproductive years, and postmenopause. Postmenopausal bleeding must be thoroughly investigated to exclude malignancy and ensure appropriate treatment.

Revision Date:

March 29, 2022