Postmenopausal bleeding - causes, diagnosis and treatment

Absence of periods for around one year is considered as attaining menopause.
Usually menopause occurs after 45 years in many women.
Some women may attain menopause before 40 years. This can be considered as premature menopause.
Some women may get menstrual periods till 50 years.
This can be familial, depends on general health etc.
Having menstrual cycles above 50 years should be carefully followed.
Some women may complain of bleeding per vaginum after attaining menopause.
This is called post menopausal bleeding.
The possible causes are :
- During menopause, endometrial layer gets atrophied. That can lead to exposure of underlying blood vessels and can increase their fragility, leading to bleeding.
- After menopause, vaginal mucosa will become thin and dry. Mild friction like during intercourse etc can induce bleeding.
- In case of any associated utero vaginal prolapse, decubitus ulcers etc can present and can lead to bleeding.
- Usage of vaginal pessary for utero vaginal prolapse  lead to local abrasions, ulcers etc leading to bleeding.
- Insertion of foreign objects can lead to bleeding sometimes.
- Obesity by increasing estrogen levels can cause endometrial hyperplasia and bleeding.
- Presence of cervical erosion etc can lead to bleeding sometimes.
-Uterine infections can also lead to postmenopausal bleeding.
-Usage of continuous hormone replacement therapy can lead to thickening of endometrium, polyps etc, and can lead to bleeding.
Eg : tibolone

- Cervical malignancy can lead to postmenopausal bleeding.
-Endometrial malignancy can lead to postmenopausal bleeding. Sometimes hormone replacement therapy can cause this.
-Rarely leiomyosarcoma from fibroids can cause bleeding.
-Hormone secreting ovarian tumors can lead to endometrial changes sometimes and can lead to postmenopausal bleeding.
- Usage of anticoagulants can lead to postmenopausal bleeding in some women.

Diagnosis :
Any type of postmenopausal bleeding to be considered serious and should be carefully evaluated.
Physical examination helps in ruling out local causes like cervical erosion, polyps, cervical neoplasia, ulcers, foreign objects etc.
It also helps in finding out the size of the uterus.
- Ultrasound especially transvaginal ultrasound can detect endometrial thickness, uterine size, polyps etc.
In case of suspected malignancy, MRI is more useful.
-Endometrial biopsy helps to do histopathological examination of tissue.
- Pap smear and cervical biopsy will help in ruling out the cervical neoplasia.
-Hysteroscopy helps indirect visualization of endometrial tissue,  to take biopsy and to remove polyps etc.
-Dilatation and curettage (D&C) helps to get the tissue for histopathological examination. It also helps for therapeutic purpose also.
-Coagulation profile to detect deficiency of clotting factors etc.

Treatment :
 Treatment of postmenopausal bleeding depends on cause.
- Endometrial atrophy needs hormone replacement mainly with minimal dose of estrogen.
- Minimal endometrial hyperplasia may be treated with progesterone support.
Endometrial hyperplasia with polyps can be treated with D&C followed by progesterone pills.
- Simple endometrial hyperplasia can be followed with regular checkups and ultrasound examinations.
- Infections can be treated with antibiotics.
-Cervical erosion may need cryotherapy sometimes.
- Stopping the drugs of hormone replacement therapy, anticoagulants etc can cure the problem sometimes.
- In case of early stages of cervical or endometrial neoplasia, total hysterectomy with bilateral salpingo-oopherectomy can help.
- In case of advanced malignancies radical hysterectomy with chemotherapy and radio therapy are needed.



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