Causes of Postmenopausal Vaginal Bleeding
Primary Concern: Malignancy
Endometrial cancer is the most serious etiology and must be excluded first, though most postmenopausal bleeding has a benign cause. 1 Approximately 10% of women presenting with postmenopausal bleeding will have endometrial cancer, with peak incidence between 65-75 years of age. 2
Complete Differential Diagnosis
Malignant Causes
- Endometrial carcinoma - Present in approximately 10% of cases, making it the primary concern requiring urgent exclusion 1, 2
- Cervical carcinoma - Must be evaluated during speculum examination 2
- Ovarian cancer - Particularly hormone-producing ovarian tumors that can stimulate endometrial bleeding 1
- Uterine sarcoma - Risk increases with age, up to 10.1 per 1,000 in patients 75-79 years old 1
Benign Structural Causes
- Atrophic endometritis and vaginitis - The most common benign cause, accounting for 21.2% of cases 3
- Endometrial polyps - Common structural lesions visualized on transvaginal ultrasound or hysteroscopy 1
- Endometrial hyperplasia (with or without polyps) - Represents a precursor to endometrial cancer and requires tissue diagnosis 1
- Cervical polyps - Identified during speculum examination 2
- Submucous leiomyomas (fibroids) - Even in the presence of fibroids, malignancy must still be ruled out 1
- Cervical stenosis with hematometra - Bleeding occurs when the obstruction releases 1
Infectious/Inflammatory Causes
- Chronic pelvic inflammatory disease with hydrosalpinx or pyosalpinx 1
Medication-Related Causes
- Hormone replacement therapy (HRT) - Estrogens can cause abnormal uterine bleeding and increase risk of endometrial cancer 4
- Selective estrogen receptor modulators (SERMs) like tamoxifen - Slightly increase the risk of endometrial cancer 1
- Anticoagulants - Can contribute to bleeding 2
Rare Causes
- Hematological malignancies - Chronic lymphocytic leukemia with endometrial infiltration has been reported, though rare 5
Critical Clinical Pitfall
The overall incidence of genital tract malignancies in patients presenting with postmenopausal bleeding is 16%, making urgent referral and thorough investigation mandatory. 3 All women with postmenopausal bleeding should be referred urgently regardless of age or presumed benign etiology. 2
Age-Specific Consideration
Women under age 50 with postmenopausal bleeding have a notably lower risk of endometrial cancer - in one study of 260 women under age 50, zero cases of endometrial cancer were found. 6 However, this does not eliminate the need for proper evaluation to exclude other pathology.