Clinical Treatment for Post-Menopausal Bleeding

Postmenopausal bleeding is defined as uterine bleeding after a woman has been menopausal for a year or more.

Before menopause women have periods every 21-30 days, or monthly.  Most women can anticipate when they are going to have a period and are prepared for it, so it becomes a fact of life.

Uterine bleeding is necessary monthly because human females are fertile once a month, they prepare the egg for the first 14 days of their cycle, the egg is ovulated or pushed out of the ovary and travels down the fallopian tube where it is fertilized by sperm that are deposited in the vagina. During the second 14 days of the cycle, the uterus prepares a thick lining under the influence of high estradiol and progesterone levels, so a fertilized egg can nestle in and begin to divide and eventually become a human baby.

A human egg is fertile for only about 36 hours after ovulation and if it is not fertilized it disintegrates, and   when it gets to the uterus it doesn’t need the lining of the uterus to nurture a baby, so Estradiol and Progesterone drop precipitously and the signal to the uterus is to shed the uterine lining.  With no estradiol or progesterone to feed the lining it bleeds out the uterus and we call that a period.

This cycle goes on and on unless a woman is on the pill during which time the orchestrated elevations and decreases of the female hormones coming from the ovary are suppressed.  The pill gives women a very low estrogen and progesterone blood level, which prevents the increase and decrease of the female hormones and the lining of the uterus does not thicken.  Of course, this is not a perfect program, and some women spot and bleed all the time during their cycle.  This can be because their own estrogen and progesterone is not suppressed enough, and their lining gets too thick, or their own estradiol is too low, and their lining is too thin, and they spot from a fragile and thin uterine lining.

Before menopause other problems can come into play that make the uterus misbehave, such as benign growths like polyps and fibroids.  These growths can happen to anyone…it is no one’s fault, but they don’t behave like they should and people with these growths often bleed off and on for no reason and no way to predict the pattern.  Often, they have to be surgically removed to stop an irregular bleeding problem. 

Post-menopausal bleeding is defined as uterine bleeding after a woman has been menopausal for a year or more. Post-menopausal bleeding is often a side effect of any type of estradiol and progestin or progesterone postmenopausal hormone therapy.  PMP Bleeding is usually a bother, and not a sign of cancer or a uterine fibroid or polyp. If a woman has two episodes of bleeding after menopause her doctor must make sure her problem is benign by a uterine ultrasound and or a uterine biopsy in the office or a D&C to clean the uterus out.  These procedures reassure the doctor and patient that the bleeding is not a serious problem, and in the case of a D&C, this procedure removes all of the tissue from the uterus to both diagnose and treat the uterine bleeding.

Any bleeding after a D&C for the following year is not considered cancer because uterine cancer is slow growing and won’t grow from nothing to cancer in one year.

What is the Cause of Postmenopausal Bleeding (PMPB):

Post-menopausal uterine bleeding can be caused by several physiologic and anatomic situations:

1. Thick uterine lining (from high Estradiol ( E2) and low Progesterone (P)
2. just no E2)
3. Uterine Polyps in the uterus
4. Uterine fibroids
5. “Spongy” Uterus, called adenomyosis
6. Inadequate Vitamin K, Vitamin C, or clotting factors
7. Medications and Supplements such as aspirin, NSAIDS, Fish Oil, Warfarin, and other medications for treatment of blood clots.
8. Platelet deficiency (like in Leukemia and Lymphoma, or ITP)
9. Uterine Cancer (Endometrial Cancer) only 9% of all PMP bleeding is from cancer.

 Diagnosis of PMP Bleeding: 

1. Bleeding from medications, supplements or lack of vitamin K or C are the easiest things to stop to also stop the bleeding. This is the first step in stopping uterine bleeding.
2. Treating with Prometrium® or increasing the dose of the progesterone the patient is already taking is done at the same time as adjusting supplements and medications. If bleeding stops, that’s it.
3. If bleeding doesn’t respond to progesterone suppression, then a vaginal ultrasound is done to look and see if there is a thick or thin lining or if there are fibroids or polyps in the uterus.
4. If the lining is thick the GYN doctor will do an office biopsy, to make sure the lining is not cancer. If not he or she will either lower the estrogen dose, increase the progesterone, or stop estradiol all together. This always depends on the severity of the patient’s symptoms and if she is motivated to take estradiol to lessen her symptoms of menopause.
5. If there is a polyp or an unusual looking uterine lining a D&C in the operating room will allow the doctor to clean out the uterus, get a biopsy and remove polyps from the uterus.
6. If there are fibroids we treat the patient with testosterone/arimidex pellets and or a hysterectomy, or we stop treatment with estradiol.

PMP Bleeding after a D&C

Every once in a while, our patients complain of bleeding after a D&C that they had over 10 days before.  This question and answer should come from the doctor who preformed the surgery; however we are often asked if the answer they got from their doctor was inadequate.

TREATMENT OF BLEEDING AFTER A D&C:

• Patients who have had a D&C may bleed afterwards for longer than the usual 10 days after the procedure. This type of bleeding is usually from the thin uterine lining that is left in the uterus after the uterus is completely cleaned out.  A thin lining requires treatment with estradiol to help the uterus grow back a normal endometrial lining. This new lining is like a “blanket “over the raw areas left after surgery.
• Post op, D&C patients need estrogen and not progesterone. If they had a polyp it is even more important to cover the area of where the polyp was with estrogenized lining. After the D&C you may have to add a climara patch for a few weeks and not take the progesterone for 3 weeks or bring these women in for more E2 pellets. Adding progesterone is not the answer for these post D&C folks!
• Patients who have fibroids, a history of endometriosis and still have a uterus should start on at least one TA pellet with their E2 and T pellet, to prevent future bleeding and growth of fibroids while taking estrogen pellets, to prevent bleeding from the uterus itself.
• Infrequently a woman will need a hysterectomy because the uterus is so spongy that it continues to bleed from adenomyosis no matter what is done.
• If there are uterine fibroids that won’t stop bleeding that is another reason to consider a hysterectomy. Remember to leave the ovaries and cervix if at all possible and just take the uterus out.
• The ovaries are often still slightly useful for years after menopause, and the cervix is attached to the ligaments that support the pelvic floor and carry the nerves for cervical orgasms. You don’t want to lose those

It is true that many women need estradiol replacement after menopause to allow them to lead a full life, sexually and otherwise.  Unfortunately, many women are afraid of estrogen replacement because of the risk of postmenopausal bleeding and the tiny risk (9%) of women who may develop uterine cancer on estrogen replacement.

Today we took the mystery out of the use of estradiol to treat the symptoms of menopause and what can be done about it.  Hopefully this knowledge will appease the fears women have of estrogen and will allow them to take estrogen safely and enjoy a long and full life.

This Health cast was written and presented by Dr. Kathy Maupin, M.D., Bio-identical Hormone Replacement Expert and Author, with Brett Newcomb, MA., LPC., Family Counselor, Presenter and Author. www.BioBalanceHealth.com.