Postmenopausal Bleeding

In most cases, postmenopausal bleeding is not due to cancer. Common causes are:

• Inflammation of the vaginal lining (atrophic vaginitis) or lining of the uterus (endometrial atrophy) caused by lower oestrogen levels
• Cervical or uterine polyps which are not usually cancerous
• Thickening of the lining of the uterus (endometrial hyperplasia).This can be caused by HRT and Tamoxifen (a treatment for breast cancer) or by other conditions causing a high oestrogen level such as being overweight or having polycystic ovarian syndrome or type 2 diabetes.

However, postmenopausal bleeding is also a classic sign of cancer of the lining of the uterus (endometrium) and therefore it is important to be assessed by your GP. More rarely other cancers can present with postmenopausal bleeding; these include cervical cancer, uterine sarcoma, ovarian cancer and vaginal cancer.

Your GP may ask you some questions to help with making a diagnosis. These may include:

Enquiring about the bleeding:

• When it started and the quantity and duration of bleeding
• Whether anything could have set it off such as intercourse or trauma to the area
• Whether it could be from somewhere else – urinary tract or rectum

Enquiring about associated symptoms:

• Pain
• Unplanned weight loss
• Fever
• Bowel symptoms
• Urinary symptoms
• Other unexplained bleeding or bruising

Looking at your past medical history and family history.

Looking at the medications you take and whether you take them regularly – this particularly includes HRT, tamoxifen and anticoagulants.

Your GP may need to examine you. This may include pressing on your tummy and feeling inside your vagina to check for lumps, tenderness or other abnormalities. Your GP may insert a plastic or metal speculum into your vagina to hold it open so they can see the inside of your vagina and cervix. You can ask for a chaperone such as a healthcare assistant, nurse or receptionist to be in the room while your GP carries out your examination.

If you take HRT, then your GP may ask you to stop taking this for six weeks and then review you again.

If your uterus has already been removed (hysterectomy) and your GP cannot see where the bleeding is from, they may make a routine referral to gynaecology.

If you have not had a hysterectomy, then it is most likely that your GP will refer you to gynaecology using the “two-week wait” pathway. This means that you will see a specialist gynaecologist within two weeks. Although this pathway is for possible cancer, it is still more likely that your bleeding is due to one of the less serious causes. If you have not received your appointment within a few days of your GP assessment, then you should contact the practice to check what has happened.

The gynaecologist will probably want to go over the history and repeat the clinical examination which was carried out by your GP. They will explain to you and organise any further tests which are required. These tests may be carried out during your initial appointment and include:

• Ultrasound scan to get a picture of your cervix, uterus, endometrium and ovaries. An external ultrasound involves a small device being moved over your tummy. Usually, you will undergo a vaginal ultrasound as well (a small device is placed in your vagina to get a better picture of your cervix and uterus).
• Hysteroscopy and biopsy – a thin telescope-like camera is passed up your vagina, through the cervix and into the uterus to look for any problems. This is also used to take a sample (biopsy) for later examination in the laboratory. Nowadays this procedure can usually be done in the clinic under local anaesthetic as an out-patient.

Treatment depends on what’s causing your bleeding:

• Atrophic vaginitis or endometrial atrophy: you may not need treatment, but may be offered oestrogen cream or pessaries
• Non-cancerous polyps: the polyps may need to be removed by a gynaecologist
• Side effect of HRT: you may be advised to change or to stop your HRT treatment
• Endometrial hyperplasia: depending on the type of hyperplasia, you may be advised lifestyle treatment such as losing weight, or you may be offered hormone treatment(usually a progestogen hormone releasing device fitted inside the uterus). You may be advised to undergo hysterectomy.
• Cancer: total hysterectomy will often be recommended. You are likely to be looked after by a multi-disciplinary team including an oncologist (cancer expert). They will recommend what other treatments you should undergo such as radiotherapy or chemotherapy. You will also be supported by specialist nurses in the team.