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

Hormone Replacement May Be Heart-Safe During Menopause

While most women perceive breast cancer as their greatest health threat, in the United States, heart disease is the No.1 killer of women, as well as of men. An American woman is 10 times more likely to die from heart disease than from breast cancer. Because many women take statins, a class of drugs that lower cholesterol, how well these drugs work for women who are also taking hormone replacement therapy is an important question.

One of the main purposes of the Women’s Health Initiative (WHI), a large U.S. study of 161,000 women that was initiated in 1991, was to determine whether long-term hormone therapy could prevent heart disease in women and prolong life in addition to controlling postmenopausal symptoms.

The end result, released in 2002, was not the expected result.

The WHI showed that for every 10,000 women per year who used estrogen and progestogen (compared to the women who were not taking any hormones or were taking estrogen alone), there were actually seven additional myocardial infarctions (heart attacks) and eight additional strokes. Overall, hormone replacement was associated with higher heart-health risk in this study.

But what we now appreciate is that, in many ways, the study design was flawed. For one, the average age of women in WHI was 63, and more than 70 percent of the women enrolled were over the age of 60.

Age Matters for Heart Disease Risk During Menopause

A re-evaluation of the study results showed that estrogen users between ages 50 and 60 did not increase their risk of cardiovascular disease. They actually decreased their risk of coronary heart disease and overall mortality. This is an important finding because menopausal women in this age group are the ones who are the most symptomatic — and the most likely to take hormone therapy.

Other studies have confirmed that it is not only the age at which women take hormone therapy, but also the type of estrogen that matters. Beta estradiol and transdermal estrogens seem to have cardiovascular advantages over the conjugated equine estrogen that was used in WHI.

There was another important issue. WHI did not identify who was taking statin drugs, and who was not.

New Data on the Difference Statins Can Make

A new Swedish study, published in the journal Menopause, attempts to answer the question of statins’ effects on heart disease risks for women taking hormone replacement therapy.

In this study, 40,000 women took statins along with beta estradiol, compared to 38,000 who did not. Over four years, the number of deaths and cardiovascular events, such as heart attack and stroke, were recorded. The rate of death from any cause was 33 per 10,000 person-years for women who used hormone therapy with statins compared with 87 per 10,000 person years for women who used statins alone — a significant difference.

The bottom line? If a woman chooses to take hormone therapy, it appears the best time to start is at the onset of menopause. The type and route of estrogen make a difference. In addition, for women at risk for cardiovascular disease, taking a statin may decrease the risk of coronary heart events that may occur early on in hormone therapy.

In spite of this information, at this point, hormone therapy is not recommended to treat or prevent cardiovascular disease. But, as we continue to gather data, the estrogen pendulum is swinging again. Many women can feel a lot more comfortable about taking systemic estrogen — not only relieve menopause symptoms but maybe even to prolong life.

Everyday Health March 25, 2015

Everyday Health March 25, 2015

A Risky Side Effect of Hot-Flash Treatment: Bone Loss June 30, 2015 June 30, 2015

In spite of the reassurances of menopause experts like me, many women choose not to take estrogen or have been advised by their doctors to steer clear. In fact, fewer than 10 percent of women with hot flashes ultimately accept a prescription for estrogen, and many never fill it. For the 90 percent who prefer not to take estrogen, or have been told they should not, most quickly find that doing yoga, wearing layers, and avoiding red wine are not real solutions.

For years, my go-to alternative to estrogen therapy has been to prescribe a selective serotonin reuptake inhibitor (SSRI) such as Paxil (paroxetine) or a serotonin and norepinephrine reuptake inhibitor (SNRI) such as venlafaxine. It has been known for some time that these non-hormonal drugs developed to treat depression also significantly reduce hot flashes in menopausal women.

The problem, other than that women really don’t want to be prescribed an antidepressant for hot flashes when their problem is not depression, is that many women experience the known side effects of SSRIs – namely, loss of libido and weight gain. The last thing a menopausal woman needs is a drug that might sabotage her diet or an already waning sex drive!

Now there is an additional concern. A new study published in the BMJ journal Injury Prevention suggests that hot-flashing women who take an SSRI at the standard doses used to treat depression may accelerate bone loss and increase their fracture risk. This is actually not new information: Prior epidemiological studies on bone fracture risk following exposure to SSRIs have reported an association (as opposed to a cause-and-effect relationship) between SSRI treatment and fractures.

The real question: Is the same issue seen in low-dose paroxetine? Specifically, does Brisdelle (the only FDA-approved nonhormonal option for hot flash relief), with 7.5 milligrams of paroxetine, have the same side effects seen in doses of 10, 20, 30, and 40 mg of paroxetine?

In clinical trials, Brisdelle, unlike the higher doses of paroxetine used to treat depression, was not associated with a decrease in libido or an increase in weight.

At this point, it is impossible to say with certainty that 7.5 mg of paroxetine does not accelerate bone loss since this dose was not studied in the BMJ/Injury Prevention group. However, it stands to reason that 7.5 mg of paroxetine used to treat hot flashes is less likely to cause bone loss than higher doses intended to treat depression.

So, the bottom line: SSRIs are an excellent option to alleviate hot flashes if estrogen is not an option. But make sure you are bone savvy. Take your calcium, get in that weight-bearing exercise, check your vitamin D levels, and have your bone density checked according to National Osteoporosis Foundation guidelines. Know that if you are losing bone, your SSRI might be part of the problem. As with every drug with potential side effects, it makes good sense to take the lowest dose needed to treat the problem. While it’s tempting to take a less expensive higher-dose generic to alleviate your hot flashes, know it might kill your libido, put on the pounds, and possibly deplete your bones.

Cold Facts About Hot Flashes

By Lauren Streicher, MD

Published May 27, 2014, Everyday Health

The number one reason most women start systemic estrogen is to treat hot flashes once they realize that yoga, carrying a portable fan, and dressing in layers are not real solutions. Hot flashes occur in 75 percent of menopausal women and typically begin as a sudden sensation of heat on the face and upper chest that becomes generalized. A severe flash can be pretty intense (I call it the furnace inside you) lasting between two and four minutes with profuse sweating, followed by chills and shivering. Physiologically, a hot flash happens for the same reason that you sweat in a sauna… the body is trying to cool down. The difference is, you don’t really need to cool down, but your menopausal brain thinks you do. While most last 2-4 years, some women will experience flashes for up to 10 years. About 10 percent…forever.

Toughing it out works out for some women, but other’s who have severe hot flashes though out the day and nights are totally blind sided by just how debilitating hot flashes can be. Estrogen therapy will eliminate or dramatically reduce flashes, but many women choose not to take estrogen, or have been advised by their doctors to steer clear. In fact only 7 percent of women with hot flashes ultimately accept a prescription for estrogen. As an estrogen alternative, menopause experts, including myself, often prescribe one of the antidepressants which years ago were serendipitiously found to reduce hot flashes in menopausal women. This of course is the rationale for Brisdelle; the FDA approved option of low dose paroxetine, one of the selective serotonin reuptake inhibitor (SSRI) antidepressants.

While numerous scientific studies have shown that many antidepressants are effective at reducing hot flashes, no studies have compared antidepressants, estrogen and placebo in the same study.

In the May 27 issue of JAMA, a new research study is published looking specifically at this issue. 339 peri and postmenopausal women in the study took estrogen, venlafaxine (an antidepressant), or a placebo for 8 weeks. Women that took the venlafaxine had a reduction in hot flashes that was essentially as good as women that took low dose estrogen.

In addition to flash frequency, this study also looked at “treatment satisfaction” and interference of symptoms with daily life and found that treatment satisfaction was highest for estradiol, intermediate for venlafaxine, and lowest for placebo.

The study is somewhat limited in that it was short (only 2 months) and did not evaluate libido or weight gain, both of which have been shown to be affected by antidepressants used in typical doses used to treat depression. That evaluation would require a longer study and more women. But, be that as it may, this is still important information and confirms that venlafaxine, like other SSRI’s and SNRI’s, at least in the short term, not only reduces hot flashes, but does it almost as well as estrogen.

Every once in awhile someone will say, my grandmother didn’t take anything for hot flashes, why should I? Well grandma was more likely to be home baking cookies than doing a job that required a good night’s sleep and the ability to think clearly. Grandma may have been having occasional sex with Grampa, (there’s a visual I didn’t need to give you!) but was unlikely to be starting a second marriage or a new relationship in her 50’s. Grandma likely did not live nearly as long as you will. So whether you chose to take hormone therapy or an alternative, if your flashes are getting in the way of your sleep, your sexual health or your quality of life, know that you have options.