What causes postmenopausal bleeding?

The likelihood of postmenopausal bleeding being cancer may not be very high, but it is a cause of concern and needs medical attention immediately, says gynaecologist Dr. Anuradha Sharma.

According to a study published in the Journal of the American Medical Association (JAMA) Internal Medicine, postmenopausal bleeding occurs in about 90% of women with endometrial cancer; but only only 9% of women with postmenopausal bleeding were diagnosed with endometrial cancer.

While gynaecological cancers are among the most common cancers in women around the world, in India the rate of endometrial cancer is relatively low, according to research. We spoke to Dr. Sharma, a Delhi-based gynaecologist, about the causes, risk factors, diagnosis of postmenopausal bleeding, and whether it can be an indicator of endometrial cancer. Edited excerpts:

• What is postmenopausal bleeding? What are the most common causes of postmenopausal bleeding?
• Is bleeding after menopause always cancer?
• So, even benign polyps or fibroids can cause heavy bleeding?
• Is there a particular timeframe that postmenopausal bleeding could happen in?
• You said that it could be a sign of endometrial cancer, could you tell us more about it?
• How do you diagnose it?
• Can postmenopausal bleeding stop on its own?
• Is there a common age where the incidence is higher?
• Is there any way to prevent it?
• Can stress cause postmenopausal bleeding?
• What about the relationship between diabetes and postmenopausal bleeding?

What is postmenopausal bleeding? What are the most common causes of postmenopausal bleeding?

Menopause is when you stop getting your period for a year. After that if you have any bleeding, it is known as postmenopausal bleeding. The incidence is somewhere around 5-15%. There are various reasons for it. There could be an endometrial atrophy (thinning of the uterine lining), polyps (mostly non-cancerous growth on the inner wall of the uterus), tumour, or any other kind of growth inside the uterus.

Postmenopausal bleeding can be hormonal. Post menopause, the production of estrogen and progesterone falls, which causes the lining of the endometrium to become thin and it starts shedding. That could be a cause for postmenopausal bleeding. Another reason can be endometrial hyperplasia, wherein the uterine lining thickens leading to excess bleeding. This is caused because of excess estrogen and low progesterone to offset its effects. Apart from these reasons, there could be other infections and malignancies which can cause postmenopausal bleeding.

Some women worry that bleeding after menopause is always cancer. What percentage of postmenopausal bleeding is cancer?

No, it isn’t always cancer. The incidence of cancer in cases of postmenopausal bleeding is somewhere around 10%. But it should never be ignored. It is a sign of an emergency, it is an alert that you should visit your doctor. There is a likelihood of endometrial cancer, especially  if you are comorbid with diabetes or hypertension. Diabetics have a higher incidence of developing cancer if they have postmenopausal bleeding.

The incidence of cancer in cases of postmenopausal bleeding is somewhere around 10%. But it should never be ignored. It is a sign of an emergency, it is an alert that you should visit your doctor.

So, even benign polyps or fibroids can cause heavy bleeding?

Yes, they absolutely can. Polyps grow inside the uterus or the cervix, they are usually benign but they can cause bleeding or spotting. You have to be investigated by a doctor.

Is there a particular timeframe that postmenopausal bleeding could happen in — say after a few months post menopause or a few years post menopause?

Not really, it can happen many years after menopause as well. That is mostly cancer, or it is atrophic, which means that the hormone levels have dropped so low that the endometrium becomes papery thin and it starts shedding. There is nothing to support it, so it sheds off.

You said that it could be a sign of endometrial cancer, could you tell us more about it?

The endometrium is the lining of the uterus. And, abnormal vaginal bleeding, post menopause or in between periods is a sign of endometrial cancer. It can also cause pain during sex.

Endometrial cancer can happen anytime, especially post menopause. And  it will cause abnormal bleeding. Throughout a woman’s reproductive lifetime also, if there is any irregular bleeding, it has to be investigated. Especially post menopause, because if you have already had menopause, there shouldn’t be any bleeding anymore.

Endometrial cancer can happen anytime, especially post menopause. And it will cause abnormal bleeding. Throughout a woman’s reproductive lifetime also, if there is any irregular bleeding, it has to be investigated.

How do you diagnose it?

There is a basic blood test to rule out diabetes, and then you will need a general examination, an ultrasound. Depending on the results of the ultrasound, you may have to get an MRI. An MRI gives the doctor detailed pictures of the uterus, abdominal tissue, and lymph nodes and can help in detecting cancer. If there is any  suspicion of cancer, you will have to get a hysteroscopy. This enables the doctors to get tissue for a biopsy.

(Hysteroscopy is a procedure wherein a hysteroscope is inserted into the vagina to examine the uterus and the cervix.)

If the results of the biopsy are unclear, a dilation and curettage (D&C) procedure is also useful in diagnosing endometrial cancer. This procedure involves dilating the cervix and scraping tissue from inside the uterus, which is tested for cancer. 

Can postmenopausal bleeding stop on its own?

If it is atrophic, or hormonal, then it can stop on its own. However, that is not an indication that you don’t have to see a doctor. You absolutely must see a doctor.

Is there a common age where the incidence is higher?

Not necessarily. Maybe soon after menopause, if there is a polyp or a fibroid then it might bleed a little earlier, but there isn’t any specific age for it. You have to be on your guard if there is bleeding.

Is there any way to prevent it?

The best prevention is routine gynaecological checkup. All women must get a routine gynae checkup at least once a year, despite your age. 

The best prevention is routine gynaecological checkup. All women must get a routine gynae checkup at least once a year, despite your age. 

If you are obese, diabetic, hypertensive, you definitely have to control these. Lifestyle modification always helps. If you are overweight, you must reduce your weight. If you have blood sugar, you have to manage it well. Also, meditation, exercise, yoga, all of these practices help. If you are stressed, it is important to get help and manage stress in whichever way works best for you.

Can stress cause postmenopausal bleeding?

Psychology plays an important role. It affects the whole system. It can affect the uterus as well. But only stress causing postmenopausal bleeding, you cannot label it as a cause. But it can play an important role especially in hormonal imbalances. Anxiety, depression, mood swings can all cause physical and mental stress which isn’t good for your health in general.

What about the relationship between diabetes and postmenopausal bleeding, are diabetic women more prone to postmenopausal bleeding?

Diabetes means that you have high glucose levels, it impacts your metabolism, and there is an increased chance of cellular changes, of infections. There are also some studies which say that women with type 2 diabetes are more at risk for endometrial cancer. But diabetes is more common in people who are obese and have a less active lifestyle, and obesity and a sedentary lifestyle are anyway a risk factor for endometrial cancer.

Sources:

Gynecological cancers: A summary of published Indian data. Amita Maheshwari, Neha Kumar, and Umesh Mahantshetty

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