It is important to differentiate an abnormal vaginal bleed from a menstrual bleed (periods) within the reproductive years of a woman’s life. However, once menopause sets in then any vaginal bleeding may be considered abnormal. Bleeding after menopause may not always due to serious causes but should be investigated as it can at times be a sign of cancer.
When is Menopausal Bleeding Abnormal?
Vaginal bleeding after menopause is not an uncommon occurrence and there may be the odd instance of abnormal vaginal bleeding which should not be a cause for concern. This post-menopausal bleeding is usually mild spotting or a light flow that lasts for a day or two. If it is a heavy flow, persisting for a long period of time or resembles a period (menses), then it warrants further investigation.
Before diagnosing a post-menopausal bleed, it is important to first confirm that menopause has set in. Cessation of periods after the age of 40 years is not necessarily menopause unless your periods have stopped for 6 consecutive months. Other causes of cessation of periods (amenorrhea) has to be excluded. For example, certain drugs can cause periods to stop. In a middle-aged woman this is due to the drug and not menopause.
Prior to menopause, women enter a period known as perimenopause. It is a gradual transition to menopause during which the symptoms menopause arise. The periods may also stop for a month or two but return thereafter. Menstrual bleeding is erratic until there is complete cessation of the periods. After 6 months of no bleeding (amenorrhea), menopause can be confirmed. However, bleeding thereafter may then be considered as am abnormal menopausal bleed.
Causes of Abnormal Bleeding in Menopause
The causes of menopausal bleeding can be divided into different categories:
- Pathological causes refer to disorders and diseases that usually affect the female reproductive system and leads to abnormal menopausal bleeding.
- Iatrogenic causes are where bleeding occurs as a result of medication, physical examination or diagnostic procedures.
Bleeding is a sign of a break in blood vessels as well as the skin surface or lining of a cavity. It can occur with a host of different conditions. It is therefore important to seek medical attention to identify the exact cause. Early diagnosis and prompt treatment can greatly improve the outcome and prevent complications.
Injury to the vagina and sometimes extending as high as the cervix and uterus may be the cause of sudden postmenopausal bleeding. This can occur physically with forceful sexual intercourse or during medical procedures as discussed below. Chemical injury caused by vaginal douches can occur if there are harsh chemicals that irritate or injure the vaginal lining.
Drugs and Procedures
There are several iatrogenic causes of abnormal bleeding during or after menopause. The two most likely causes have been discussed below. Various other drugs can also be responsible for abnormal vaginal bleeding.
- Hormone replacement therapy (HRT). This is the most common cause of post-menopausal bleeding which occurs due to the estrogen in HRT. However, stopping HRT may not necessarily stop the bleed immediately. Some women experience vaginal bleeding for a short period of time after stopping hormone replacement therapy.
- Diagnostic procedures. Vaginal bleeding may occur after certain diagnostic procedures where there may be trauma to the vagina or cervix. This can occur with an endometrial biopsy, pap smear or even a gynecological examination, although the latter is less likely unless there is vaginal atrophy.
Various benign (non-cancerous) and malignant (cancerous) growths within the reproductive tract can cause abnormal bleeding.
- Uterine polyps are growths that protrude from the wall of the uterus. It tends to cause a light bleed or mild spotting which may occur at irregular intervals. These growths are more common with menopause.
- Uterine fibroids are benign tumors that originate from the muscle layer of the uterus (myometrium). In this case, the bleeding is not as light as in a uterine polyp but is usually not as heavy as a period.
- Uterine prolapse occurs when the uterus collapses from its normal position into the vaginal canal. The risk is usually higher in women who have had one or more vaginal births and it is one of the reasons women opt for an elective cesarean section in the earlier years of life.
- Hyperplasia of the endometrium is an overgrowth of the uterine lining. This may not be associated with cancer but in a significant number of cases, this overgrowth may be precancerous.
- Cancer. Any malignancy of the vagina, cervix, uterus or ovaries may lead to bleeding after menopause. Ovarian and cervical cancer are among the more common types. On its own, abnormal bleeding should not be immediately associated with cancer.
- Vaginal atrophy is the thinning of the walls of the vagina as a result of low estrogen levels with inflammation of the inner lining of the vaginal wall. Bleeding does not often occur spontaneously and tends to appear after sexual intercourse.
- Infections of the urinary tract infection (UTI) or female reproductive organs (pelvic inflammatory disease) may cause bleeding from the urethra or vagina, respectively. Most of these infections are caused by bacteria and some may be due to protozoa and viruses. Infections can be sexually transmitted.
- Lichen sclerosus is a rare skin condition that tends to affect the skin of the vaginal and anal areas. There may be patches of white skin with cracking or ulcerating that may bleed especially after sex.
It is always advisable to consult with a medical professional about an abnormal vaginal bleed, whether it is before, during or after menopause. However, immediate and emergency medical attention may not be necessary. A minor bleed that occurs with no other symptoms is not a medical emergency. If it resolves spontaneously and does not occur again then it may not be a cause for concern.
However, when there is postmenopausal bleeding that is ongoing then medical attention is necessary. The condition should be considered more serious if there is heavy blood loss as well as other symptoms like pain, fever and any foul-smelling discharge. Worsening symptoms like bleeding or pain require emergency medical attention. An ongoing bleed, even if minor, along with unintentional weight loss should be seen as serious warning signs of cancer.