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

Uterine Cancer: Beating the Odds

By Lauren Streicher, MD 


Most women are surprised when I tell them that endometrial (uterine) cancer, not ovarian cancer, is the most common gynecologic malignancy and the fourth most common cancer in women. The reason uterine cancer is not the first to come to mind is that since most uterine cancer is diagnosed in its early stages, comparatively few women die from it. Five-year survival for women diagnosed before the cancer has spread is 95%.

Abnormal bleeding is usually the first sign of a problem, which is why irregular periods, heavy bleeding or constant spotting should never be ignored. Any bleeding in a postmenopausal woman should be evaluated. The majority of abnormal bleeding is not an indication of cancer, but still needs to be checked out.

A sample from the lining of the uterus (no cutting involved!) is performed in the doctor’s office to detect pre-cancerous or cancerous cells. A Pap test, on the other hand, detects abnormal cervical cells and does not screen for uterine cancer.

Most uterine cancers occur because there is a hormonal imbalance that results in an abnormal buildup in the cavity of the uterus. In a normal menstrual cycle, women produce estrogen, which thickens the uterine lining. Ovulation, or the monthly release of an egg, triggers the production of progesterone, which prevents the uterine lining from getting too thick. If someone isn’t ovulating, the lining of the uterus gets blasted with estrogen but without the progesterone to balance it out, the potential for cancerous changes increases.

The only thing better than early detection of uterine cancer is to prevent it from developing in the first place. Here are 5 steps that can reduce your risk:

Lower Your Weight to Lower Your Risk
Fat cells produce estrogen, which is why obesity is thought to be one of the primary reasons endometrial cancer rates are increasing in the US. Women who are obese are more than three times as likely to get endometrial cancer.

A Pill a Day …

Every woman knows that taking birth control pills helps prevent pregnancy, but taking oral hormonal contraception for at least 12 months also decreases the risk of uterine cancer. The longer you take them, the more your risk is reduced – taking them for three years or longer may reduce risk by a whopping 30 to 80%. This protection may last for 15 years after pill use is discontinued.

Choose an IUD
Birth control pills are not the only type of contraception that reduces uterine cancer. The progestin in the Mirena™ intrauterine device also keeps the lining of the uterus from building up. Mirena IUDs are now used to treat a pre-cancerous condition called hyperplasia.

Pick Your Progestin

It has been known since the 1970s that taking estrogen therapy without adequate progestin increases the risk of uterine cancer almost tenfold. If you are taking estrogen for relief of menopausal symptoms (and have a uterus), it is crucial to take an appropriate progestin to protect the lining of the uterus. Compounded progestin creams have not been shown to offer adequate protection. The progestin molecule is too large to be absorbed well through the skin, which is why the FDA approved progestins used to balance estrogen therapy are in pill form.

Question Your Kin
Many women have heard of BRCA gene mutations that are associated with breast and ovarian cancer. But BRCA is not the only genetic mutation. Families with a Lynch mutation are not only at risk for colon and stomach cancer, but also have a 20 to 60% chance of developing uterine cancer as opposed to approximately 3% in the general population.

originally published 11/14 2013