What are the causes and treatments of bleeding during menopause?

Causes and Treatments of Bleeding During Menopause

Postmenopausal bleeding requires urgent evaluation to rule out endometrial cancer, which occurs in approximately 10% of cases, while most bleeding has benign causes. 1

Causes of Postmenopausal Bleeding

Common Causes

• Endometrial atrophy - most common cause due to reduced estrogen levels 2
• Endometrial hyperplasia - abnormal thickening of the endometrium 1
• Endometrial polyps - benign growths in the uterine lining 1
• Cervical polyps - benign growths on the cervix 1
• Vaginal atrophy - thinning of vaginal tissues due to estrogen deficiency 1
• Submucosal fibroids - benign tumors in the uterine wall 3

Serious Causes

• Endometrial cancer - present in approximately 10% of women with postmenopausal bleeding 2, 1
• Cervical cancer - may present with abnormal bleeding 1
• Ovarian tumors - hormone-producing tumors can cause bleeding 1
• Hematological malignancies - rare cases of blood disorders infiltrating the endometrium 3

Medication-Related Causes

• Hormone replacement therapy (HRT) - breakthrough bleeding is common, especially during the first months of treatment 4
• Tamoxifen - can cause endometrial hyperplasia and increase bleeding risk 1
• Anticoagulants - may exacerbate underlying bleeding tendencies 1

Diagnostic Approach

Initial Evaluation

• Transvaginal ultrasound (TVUS) is the recommended first-line imaging test 5
  • Endometrial thickness ≤4 mm indicates low risk of endometrial cancer 5
  • Can identify structural abnormalities of the uterus, endometrium, and ovaries 5

Further Diagnostic Testing

• Office endometrial biopsy is the standard method for obtaining tissue for histological assessment 5
  • Has a false-negative rate of approximately 10% 5
• If office biopsy is negative but bleeding persists, or if biopsy is non-diagnostic, fractional dilation and curettage (D&C) under anesthesia should be performed 5
• Hysteroscopy may be helpful in evaluating the endometrium for lesions such as polyps in patients with persistent or recurrent undiagnosed bleeding 5
• MRI can be considered if TVUS cannot adequately evaluate the endometrium due to patient factors or pathology 5

Important Considerations

• Even in the presence of fibroids, uterine sarcoma and endometrial cancer must be ruled out 5
• Risk of unexpected uterine sarcoma is higher in older patients, up to 10.1 per 1,000 in patients 75-79 years of age 5

Treatment Options

For Atrophic Vaginitis/Endometrium

• Local estrogen therapy (vaginal creams, tablets, or rings) 6
  • Minimizes systemic absorption while treating local atrophy 6
  • Should be used at the lowest effective dose 6
• Systemic hormone therapy only if local therapy ineffective and benefits outweigh risks 6

For Endometrial Hyperplasia

• Progestin therapy (oral or intrauterine) to counteract estrogen effects 7
• When estrogen therapy is prescribed for a postmenopausal woman with a uterus, progestin should also be initiated to reduce the risk of endometrial cancer 6

For Heavy Bleeding (Perimenopausal)

• Intrauterine levonorgestrel device - most effective medical therapy 8
• Oral progestogens - can help regulate and reduce bleeding 8
• Tranexamic acid - reduces bleeding by inhibiting fibrinolysis 8
• NSAIDs (like mefenamic acid) - can reduce bleeding by 20-50% 8, 7
• Combined oral contraceptives - for women without contraindications 8

For Structural Abnormalities

• Surgical removal of polyps via hysteroscopy 5
• Myomectomy or hysterectomy for symptomatic fibroids 5
• Endometrial ablation for persistent bleeding without malignancy 5

For Malignancy

• Referral to gynecologic oncology for appropriate surgical management and staging 5, 1

Special Considerations

Hormone Replacement Therapy and Bleeding

• Breakthrough bleeding is common with HRT and is often the single most important factor deterring women from continuing treatment 4
• Unscheduled bleeding during the first 1-2 years of therapy is common 7
• Women on HRT with abnormal bleeding should be evaluated to rule out endometrial pathology 6
• Use the lowest effective dose of HRT for the shortest duration consistent with treatment goals 6

Antiplatelet Therapy After Cardiovascular Events

• Women on antiplatelet therapy may experience heavy menstrual bleeding 7
• Management options include:
  • NSAIDs for short-term treatment (5-7 days) 7
  • Hormonal treatment with low-dose combined oral contraceptives or estrogen for short-term treatment (10-20 days) if medically eligible 7
  • Tranexamic acid may be considered, though caution is needed in those with cardiovascular disease 7

Pitfalls to Avoid

• Assuming bleeding is normal in perimenopausal women - all postmenopausal bleeding requires evaluation 1
• Relying solely on endometrial biopsy without imaging - complementary approaches are needed 5
• Initiating hormone therapy without proper evaluation of bleeding - malignancy must be ruled out first 6
• Failing to consider rare causes of bleeding such as hematological malignancies 3
• Dismissing persistent bleeding despite normal initial evaluation - further investigation is warranted 5

Remember that postmenopausal bleeding should always be evaluated promptly, as early detection of endometrial cancer leads to better outcomes 1.