Bleeding After Menopause? Don’t Go With That Flow!

by Lauren Streicher, MD 

It’s always disconcerting to have unexpected vaginal bleeding, but it’s particularly unsettling when it occurs years after your uterus and ovaries have closed for business and you no longer possess a pad or a tampon. It’s not just about making the midnight run for sanitary products, it’s that stomach-dropping fear that “blood equals cancer” that causes women to spend hours searching the Internet for reassurance. In spite of the fact that most women imagine the worst, in the majority of cases, postmenopausal bleeding is not an indication of anything serious.

So, if you see red and you’re not supposed to  … what next?

The first step is to determine where the blood is coming from. Blood on the toilet paper can be coming from the vagina, rectum or bladder, and while it seems as if the source should be obvious, it’s not always easy to know. When in doubt, put a tampon in (you may have to borrow one from your daughter). If the tampon stays white but there is blood in the toilet bowl, it’s most likely coming from the rectum or bladder and a visit to your primary care doctor is in order.  

The best time to see your gynecologist about abnormal vaginal bleeding is while you are bleeding so we can determine not only where it’s coming from, but also how heavy it is. Your description helps, but I have learned over the years that one woman’s spotting is another woman’s hemorrhage. Many women are hesitant to be examined while bleeding, but as I overheard my nurse once say to one of my patients who was reluctant, “Don’t worry. Here, everyone either arrives bleeding or leaves bleeding.” Not exactly how I would have phrased it, but somewhat accurate nonetheless.

So, short of cancer, what causes most postmenopausal bleeding?

A bloody vaginal discharge is commonly due to dryness and thinning of vaginal tissue from lack of estrogen. Vaginal infections such as yeast or bacterial vaginosis are another culprit.

Bleeding originating from the cervix can occur if there is a benign cervical polyp or cervical inflammation. Many sexually transmitted infections can cause cervical bleeding; if there is a new partner in your life, it is a good idea to be screened for chlamydia, gonorrhea and trichomonas. Cervical and vaginal cancers can also cause bleeding, but are less common.

Abnormal bleeding from the cavity of the uterus is caused by hormonal imbalances, benign growths such as polyps or fibroids, pre-cancer or cancer. An ultrasound combined with a sample of tissue from the inside of the uterus will generally identify the problem. Years ago, a surgical dilatation and curettage was the only way to obtain tissue. Now, a quick office procedure is usually performed in which a thin flexible catheter is threaded through the cervical opening into the uterine cavity.  The catheter has a suction device on it such that a tiny amount of tissue can be aspirated and sent to the lab for analysis. Most uterine samples yield reassuring results, but on occasion uterine cancer, the most common gynecologic malignancy and the fourth most common cancer to occur in women, is detected. 

Since uterine cancer is usually diagnosed in its early stages  (when a woman first experiences abnormal bleeding), there is a high cure rate. In fact, the five-year survival for women diagnosed with a Stage I cancer is 96%. 

While the overwhelming majority of abnormal bleeding is not an indication of uterine cancer, DON’T put off that trip to your gynecologist … and DON’T wait for the bleeding to stop!

Originally published 6/07/2011