Filtered By: Lifestyle
Lifestyle

Women Talk: Bleeding after menopause


Monica was a school teacher who at 62 years old looked forward to retirement. Her last menstrual period was about 12 years ago, and since then she never had any vaginal bleeding. She was a widow, and her two children lived abroad with their own families. She was healthy and slim, and didn’t smoke, and exercised regularly. She came to see me because three days before she suddenly had vaginal bleeding, soaking her underwear, and had been spotting since then. She had not had any sexual activity since her husband died 10 years ago, and had not taken any medicines that may contain hormones.

When a woman at the age of around 48 and beyond stops menstruating for 12 consecutive months, she is deemed to be in menopause. For many women, this is indeed a liberating time, when one need not worry about sanitary napkins, swimming schedules, and even packing for weekend getaways. Majority of women will at first notice some irregularities in the frequency of their periods during their late forties. Menses are skipped, and/or the volume of the flow becomes scantier, until menses cease all together.

In some women like Monica however, vaginal bleeding could suddenly occur after years of no menses. What could be the cause of the bleeding? And need she worry about it? The most common reason for vaginal bleeding during menopause is atrophic vaginitis, which means that the vaginal walls had become thin, dry and easily abraded, so that bleeding occurs. Many times, polyps, which are non-cancerous growths in the cervix, or myomas in the uterus, could be the reasons.

There are pre-malignant and malignant conditions in the endometrium which could cause bleeding during menopause. One pre-malignant condition is endometrial hyperplasia, which means the cells have proliferated in an unnatural way. If there are cellular changes seen under the microscope, there could be atypia, which means that abnormalities are found even inside the cells. Hyperplasia by itself is not cancer, but it is a precursor to cancer. In time, hyperplasia could become endometrial cancer, which arises from the endometrium, or the inside lining of the uterus.
 
For these reasons, bleeding during the postmenopausal period should not be taken lightly. Many women just wish for it to go away. Waiting could sometimes mean a big difference: as mentioned, a pre-malignant condition could become malignant. See your gynecologist at once, so you can be examined and worked up to determine the cause of the bleeding.

What are the usual examinations done for women with bleeding after menopause? A thorough history is usually taken, so take time to think before answering the doctor’s queries. Be frank and open—there are women who do not want to admit to sexual intercourse, or other forms of genital manipulations, especially when they are elderly or are already widowed. But this information is crucial for the doctor. Do not forget to mention too all medications taken, especially over-the-counter or over-the-Internet tablets/capsules and herbal medicines that you take: they might contain ingredients like estrogen, a hormone, which could cause the bleeding.  

A pelvic examination will then be done: a bivalve speculum (a small steel instrument) will be inserted into the vagina to look at the cervix. A normal cervix is smooth and clean, and any abrasions or abnormal growths will be noted. Many times, a small polyp could be seen peeking out of the cervical canal. Any signs of infection too will be looked for. The vaginal walls will be thoroughly inspected as well, for any abnormalities that could have caused the bleeding. Then an internal examination will be done to note the size of the uterus, as myomas, which are benign growths arising from the muscles, might be present. They, too, may also cause the bleeding. Other problems like haemorrhoids and growths in the urethra (area from which urine comes out) will also be considered.

The doctor will also request a pelvic ultrasound. This will, among other things, measure the thickness of the endometrium. If the lining of the uterus is deemed thin, then the doctor will tend to treat the condition as an atrophic endometirum, and will perhaps prescribe estrogen creams. However, if the endometrium is thick, further work-ups are needed.

Further work-ups

An endometrial biopsy is usually done, which is an out-patient procedure. This means taking a sample from the endometrium and sending it to the laboratory for microscopic examination by the pathologist. In some cases when bleeding is moderate or profuse, a D&C (dilatation and curettage) is done. This is cleaning out the contents of the uterus using a sharp curette under anesthesia, and will stop the bleeding for the moment. The woman usually needs to stay overnight in the hospital for this. When available, a hysteroscopy is used. This is a telescope-like instrument that could be inserted inside the uterus (through the vagina) and the magnified structures could be seen clearly. Biopsy could be then be done under direct vision of the gynecologist.

If the results of the microscopic (histo-pathological) examination show benign conditions like polyps, the woman is reassured, and is advised to have a yearly gynaecologic exam as follow-up. If however, the results show pre-malignant (as mentioned, this is termed “hyperplasia” which could be “Simple” or “Complex” depending on what the pathologists see), the doctor will discuss the options. Many gynecologists would advise a removal of the uterus (hysterectomy), fallopian tubes and ovaries (salpingo-oophorectomy). If frankly malignant, the woman is usually referred to a gynaecologic oncologist, subspecialists who have training in cancer surgery of pelvic organs. The surgical procedure to be done will be more extensive, and it includes sampling of lymph nodes in the pelvic areas to know the precise extent of the disease.  

For Monica, the ultrasound results showed a thick endometrium. The endometrial biopsy showed complex hyperplasia with atypia, a pre-malignant condition. She underwent pelvic surgery with the removal of her uterus, fallopian tubes and ovaries. Monica recovered well after her surgery, and looked forward to meeting her students again. — BM, GMA News

Dr. Alice M. Sun-Cua is an author and a practicing obstetrician-gynecologist at the San Juan de Dios Hospital in Pasay City.

LOADING CONTENT