Causes of Vaginal Bleeding in the Elderly
Postmenopausal vaginal bleeding has multiple etiologies, with endometrial cancer being the most critical to exclude (present in approximately 8-10% of cases), though the majority of cases are benign, most commonly endometrial atrophy (50% of cases). 1, 2, 3
Malignant Causes (Must Exclude First)
Endometrial Cancer
- Endometrial cancer is the primary concern and must be ruled out first, occurring in 8-10% of postmenopausal bleeding cases 1, 2, 3
- Peak incidence occurs between 65-75 years of age, with over 90% of cases occurring in women >50 years 4, 3
- Risk increases with age—while bleeding incidence decreases with advancing age, the probability of cancer as the underlying cause increases 2, 3
Other Malignancies
- Cervical carcinoma can present with postmenopausal bleeding 2
- Ovarian cancer, particularly hormone-producing ovarian tumors, may cause bleeding 1
- Uterine sarcoma must be considered, especially in older patients where risk reaches 10.1 per 1,000 in women aged 75-79 years 1, 4
- Rare hematological malignancies such as chronic lymphocytic leukemia with endometrial infiltration have been reported 5
Benign Causes (Most Common)
Endometrial Atrophy
- Atrophic endometrium is the most common cause, accounting for 50% of postmenopausal bleeding cases 3
- Vaginal mucosal atrophy is also a frequent benign etiology 5, 2
Structural Abnormalities
- Endometrial polyps are common structural causes visualized on transvaginal ultrasound, occurring in approximately 9% of cases 1, 3
- Endometrial hyperplasia (with or without polyps) represents a precursor to endometrial cancer and occurs in approximately 10% of cases, requiring tissue diagnosis 1, 3
- Cervical polyps can cause bleeding 2, 3
- Submucous leiomyomas (fibroids) are a known cause, though even when present, malignancy must still be excluded 5, 2
Other Benign Causes
- Cervical stenosis with hematometra can cause bleeding when the obstruction releases 1
- Chronic pelvic inflammatory disease with hydrosalpinx or pyosalpinx may contribute 1
- Hormone replacement therapy (HRT) or selective estrogen receptor modulators (SERMs) like tamoxifen slightly increase endometrial cancer risk and can cause bleeding 1, 2
Non-Gynecologic Sources
High-Risk Features Requiring Aggressive Evaluation
The following factors mandate thorough cancer evaluation 4:
- Age >50 years (>90% of endometrial cancers occur in this group)
- Obesity (BMI >30)
- Unopposed estrogen exposure
- Tamoxifen use (requires annual gynecologic assessment and immediate reporting of any spotting)
- Nulliparity
- Diabetes mellitus
- Hypertension
- Lynch syndrome type II (lifetime endometrial cancer risk of 30-60%)
Critical Clinical Pitfall
Even when benign causes like fibroids are present, endometrial cancer and uterine sarcoma must still be ruled out in postmenopausal patients with abnormal uterine bleeding. 1, 4 The false-negative rate of initial endometrial biopsy is approximately 10%, and 2% of patients with initially benign or insufficient tissue may eventually be diagnosed with endometrial cancer or complex hyperplasia on follow-up. 4, 6