Postmenopausal Bleeding

Dr. Kathy Maupin and Brett Newcomb discuss the issue of postmenopausal bleeding: what it may indicate and what can be done to treat it.

Doctors are taught that postmenopausal women that begin to bleed when they no longer have menstrual cycles need to checked. This symptom is never ignored. It is serious because it can be an early indication of uterine, cervical, or some other kind of cancer. Diagnosing and treating these types of cancer can save the patient’s life. Cancer is not the only possible diagnosis of postmenopausal bleeding in women who have not had a hysterectomy, but it must be the first consideration.

Generally the first question the doctor will ask is, “how much?” The amount of blood loss is an indicator of what to consider. Remember that the bleeding is a stand-alone signal that something is wrong and it must be checked. It does not automatically mean cancer (in fact, it rarely is cancer) but we cannot and will not take the risk of not checking.

We check to see the size of the uterus and the amount of bleeding. We also examine the cervix and do a Pap smear. If all these come back negative, we move on to look at diagnoses other than cancer. We check the estrogen levels, or more specifically a type of estrogen called “estrone.” We check those levels and we do an ultrasound on the uterus. The ultrasound will tell us the thickness of the uterine lining. It needs to be 4mm or less. If the lining is 8-10mm, we do a biopsy of the lining. Depending on the circumstances and availability, we do a D&C. This involves opening the cervix and cleaning it out.

One of the options to be considered after these procedures is a hysterectomy. That will usually solve the problem.

One of the other treatment options is to balance the hormones of estrogen and progesterone. There are several ways to administer them both. I never give oral estrogen, but rather use pellets instead of creams, gels, or patches. I do give an oral progesterone. The goal here is to balance the hormones so that the woman gets the benefits of having her estrogen restored to the levels of her younger, healthier self without the bleeding of the menstrual cycle. This way she can avoid the hot flashes and sleep better and have more lubrication and healthier skin.

Other issues that can cause postmenopausal bleeding involve polyps and cysts such as a fibroid. Those we remove or treat with medications such as Dim or Arimidex. Another treatment is to provide a Mirena IUD, which will provide the progesterone that they need for a year, delivered directly to the cervix so that they do not suffer from the negative side effects that are possible.