Bleeding After Menopause: A Symptom to Report

Any vaginal bleeding after menopause needs to be checked by a doctor. The National Cancer Institute lists "vaginal bleeding after menopause" among the signs you should "check with your doctor" about. As gynecologic oncologist Dr. Christina Chu put it to NCI, "If you have bleeding after menopause, you should call your doctor and let them know."

That applies to a single episode of spotting, to bleeding that stops on its own, and to blood you only notice on toilet paper. There is no amount that is too small to mention, and there is no reason to wait and see whether it happens again.

Bleeding is the main warning sign of endometrial cancer, the cancer that starts in the lining of the uterus. In an NCI analysis of 129 studies covering more than 40,000 women, 90% of women diagnosed with endometrial cancer had reported vaginal bleeding before their diagnosis.

Looked at from the other direction, 9% of postmenopausal women who saw a doctor about bleeding turned out to have endometrial cancer. That figure ranged from about 5% in North America to 13% in Western Europe. So most postmenopausal bleeding is not cancer. Dr. Chu described it this way: "For the majority of women, it's a benign problem, but there are simple things that can be done to rule out endometrial cancer."

Timing matters because of what is at stake. NCI reports about 95% five-year survival when endometrial cancer is found early, compared with 16% to 45% once it has spread beyond the uterus.

After menopause there is no amount of vaginal bleeding that counts as normal, so nothing needs watching.

• Call 911 or go to an emergency department if… the bleeding does not stop, soaks through protection, or you pass large clots.
• Call 911 or go to an emergency department if… bleeding comes with dizziness, fainting, breathlessness, a racing heart, or pale or blotchy skin.
• Call 911 or go to an emergency department if… you have a very high temperature with shivering, confusion or fast breathing.
• Call your care team the same day if… you have any bleeding at all — one episode, light spotting, or pink or brown discharge.
• Call your care team the same day if… bleeding comes with pelvic pain, a swollen abdomen, foul-smelling discharge, or unintended weight loss.

UK guidance is that this should reach a specialist within two weeks, so ask for a date.

Bleeding can happen when starting hormone replacement therapy. NCI's Dr. Megan Clarke noted that "it's only if there's persistent bleeding after the initial 6 months" of hormone replacement therapy "that it may be more concerning." Tell your doctor either way, and be specific about when you started the medicine and when the bleeding began. Estrogen-only HRT after menopause is itself a risk factor for endometrial cancer.

NCI also lists these signs to check with your doctor about:

• Vaginal bleeding or discharge not related to menstruation
• Difficult or painful urination
• Pain during sexual intercourse
• Pain in the pelvic area

Risk factors NCI names include estrogen-only hormone replacement therapy, taking tamoxifen, obesity and metabolic syndrome, type 2 diabetes, never having given birth, early menstruation or late menopause, polycystic ovary syndrome, a family history of endometrial cancer, Lynch syndrome, and endometrial hyperplasia. Having risk factors does not make cancer certain, and having none does not mean the bleeding can be ignored.

Expect a history and a pelvic exam first. From there, the tests NCI describes include:

Transvaginal ultrasound. "An ultrasound transducer (probe) is inserted into the vagina" and sound waves are used to make images of the uterus and nearby tissue.

Endometrial biopsy. "The removal of tissue from the endometrium (inner lining of the uterus) by inserting a thin, flexible tube through the cervix and into the uterus. The tube is used to gently scrape a small amount of tissue from the endometrium and then remove the tissue samples." In NCI's reporting, Dr. Chu described this as a simple procedure similar to a Pap smear that can be done in the doctor's office and does not require anesthesia.

Hysteroscopy. "A procedure to look inside the uterus for abnormal areas. A hysteroscope is inserted through the vagina and cervix into the uterus."

Dilatation and curettage (D&C). "A procedure to remove samples of tissue from the inner lining of the uterus. The cervix is dilated and a curette (spoon-shaped instrument) is inserted into the uterus to remove tissue."

Not everyone needs all of these. NCI modeling suggested that roughly 7 women need a biopsy for 1 cancer to be found, which is another way of saying that most biopsies come back reassuring.

Call your doctor's office when you notice the bleeding, rather than waiting for a routine appointment. Say the words "bleeding after menopause" when you book, because that phrase tells a scheduler this is not a routine visit.

Before you go, write down the date bleeding started, how many episodes there have been, how heavy each was, the date of your last period, and every medicine and supplement you take, including hormone therapy and tamoxifen. Ask what the plan is if the first test is normal but the bleeding continues, because ongoing bleeding still needs an answer.

• National Cancer Institute. Endometrial Cancer Treatment (PDQ) — Patient Version. https://www.cancer.gov/types/uterine/patient/endometrial-treatment-pdq
• National Cancer Institute. A Closer Look at Postmenopausal Bleeding and Endometrial Cancer. https://www.cancer.gov/news-events/cancer-currents-blog/2018/endometrial-cancer-bleeding-common-symptom