Bleeding after menopause: Get it checked out

Bleeding after menopause can be disconcerting, but the good news is, more than 90% of the time it’s not caused by a serious condition, according to a study in JAMA Internal Medicine. That said, the study also reinforces the idea that postmenopausal bleeding should always be checked out by your doctor to rule out endometrial cancer, a cancer of the uterine lining, says Dr. Ross Berkowitz, William H. Baker Professor of Gynecology at Harvard Medical School. This is because the study also found more than 90% of women who did have endometrial cancer had experienced postmenopausal bleeding. And screening all women who experience bleeding after menopause for endometrial cancer could potentially find as many as 90% of these cancers, which are highly curable if found early.

The reassuring news on postmenopausal bleeding

The analysis found that most post-menopausal bleeding is caused by a noncancerous condition, such as vaginal atrophy, uterine fibroids, or polyps. That information doesn’t really differ from what doctors have historically thought about the incidence of endometrial cancer and bleeding, says Dr. Berkowitz. But it does finally put solid data behind those figures, which was missing in the past, he says. The researchers who conducted this study were looking for clues about postmenopausal bleeding and how it relates to endometrial cancer.

But here is why you really need to see your doctor

Endometrial cancer, which affects 2% to 3% of American women, is the most common type of gynecological cancer. According to the American Cancer Society, it most often affects postmenopausal women — 60 is the average age at diagnosis. There is currently no way to screen for endometrial cancer. Identifying it early has become a pressing issue, because the incidence of this cancer has risen gradually but steadily over the past 10 years, according to the National Cancer Institute.

“Endometrial cancer is a fairly common disease, and it’s unfortunately becoming more common due to the growing rates of obesity,” says Dr. Berkowitz. A woman’s risk of endometrial cancer can increase substantially if she is obese. Generally, risk rises among women who are 50 pounds or more above their ideal body weight, he says.

This is because of the role estrogen plays in endometrial cancer. The most common type of endometrial cancer, known as type 1 cancer, is fueled by estrogen. Estrogen is produced by body fat, so women with a larger amount of fatty tissue generally have higher levels of estrogen. They also typically have more free estrogen, an active form that produces stronger effects. This may lead to cancerous changes in the uterine lining.

How your doctor will investigate postmenopausal bleeding

If you do experience unusual or postmenopausal bleeding, make an appointment with your doctor to have the problem investigated, says Dr. Berkowitz. Your doctor will likely recommend an ultrasound, a biopsy, or both. Ultrasound can measure the thickness of the lining inside the uterus. In some women with endometrial cancer, this lining becomes thicker than usual, which alerts doctors to the possibility that it is cancerous. Not all thickened linings mean cancer, though. The ultrasound should be followed by a biopsy, even if the ultrasound doesn’t show any thickening of the uterine lining, says Dr. Berkowitz. A biopsy can often be done as an in-office procedure, in which the doctor uses a thin tube with a collection device on the end to gather some uterine cells. The sample is then examined under a microscope to check for cancer or precancerous changes.

Dr. Berkowitz stressed the importance of doing both tests, because not all endometrial cancers thicken the uterine lining. Some cases are caused by type 2 endometrial cancer, which may not produce the thickening typically seen in the more common type 1. If only ultrasound is used for screening, up to 20% of endometrial cancer cases may be missed. Many of these are type 2, which tend to be the more aggressive, invasive, and deadly. Keep in mind, a Pap test cannot detect endometrial cancer. “Assuming the patient does not have any health issues, such as serious heart disease, and is otherwise healthy, doing a biopsy would be the safest, most assured way to rule out endometrial cancer,” says Dr. Berkowitz.

Then what?

If your tests suggest that you don’t have endometrial cancer, but the bleeding comes back or continues, it’s reasonable to have it re-evaluated, says Dr. Berkowitz. If you do have bleeding again after your first evaluation and normal biopsy, most likely it’s not because cancer was missed. However, it’s worth getting checked again. “I don’t recommend waiting much more than six months,” he says. Investigate unusual bleeding early, because endometrial cancer is highly curable. “The vast majority of patients with endometrial cancer can be cured with surgery alone,” says Dr. Berkowitz.

Comments:

  1. Nancy

    I have a second bleeding episode within a month after 8 years of menopause. I will have an ultrasound this Friday and than I will see my doctor for there result on April 1st. I am very worried and try to stay calm.

  2. Leslie Kuenne

    I had post menopausal bleeding and pelvic pain and had a D and C and it ruled out endomterital cancer. Two months later I was diagnosed with stage 3c ovarian cancer after going to many doctors and being very persistent! Post menopausal bleeding can also be a sign of ovarian cancer. Make sure your doctor tries to rule that out as well! I was worried about endometrial cancer but ovarian cancer never entered my head as a worry and should have! I would have gone right away to a Gyn Oncologist and not just my regular Gyn.

  3. Kathy

    I had bleeding at age 68, more than 15 years after surgical menopause. My OB_GYN did a test and scheduled surgery within 2 weeks. The diagnosis was endometrial cancer stage 1. This was 8 years ago. Recommendation – get it checked.

  4. Cheryl

    I recently noticed spotting after 15 years of being post menopausal and didn’t think it was anything to be concerned about but went in anyway since I hadn’t been checked out in awhile. My ultrasound showed increased thickness in my uterine lining so I then had a uterine biopsy which found precanercous cells and possible uterine cancer. So I had a hysterectomy a few weeks later. My post surgical biopsy of my uterous found mostly precancerous cells but one spot of early cancer. I am so glad this was caught so early. If you have any spotting after menopause do go in and get it checked out!!! I am very grateful I did!

  5. Christine Warren

    I had post menopausal serous vaginal leakage growing progressively worse. It was sometimes tinged with pink blood. It almost cost me my life having my doctor underreact to this. My ultrasound did not show much since i had calcified fibroids. At my insistance something wrong MRI was done showing tumor. Dr. scheduled office biopsy despite knowing he could not get in my cervix for pap smears. Finally surgical biopsy showed cancer after 4 months of followup. My hysterectomy showed stage 3C papillary serous adenocarcinoma, a very poor prognosis of metastasized type 2 cancer after 5 months. I have neuropathy and lymphadema and life is not the same.

  6. Leslie

    I had spotting more than ten years after menopause. I made an appointment with my doctor who performed an examination. My uterus was within normal size limits so the doc said not to worry. The spotting stopped on its own, and I have had no further issues. It is now over fifteen years after I had the spotting.

  7. Liz

    What is missing from this article, in my opinion, is the increased chance of endometrial cancer and uterine cancer after being on tamoxifen for breast cancer treatment.

    This is kind of a big omission, in my opinion, given the highly increased chance of these cancers when treated with tamoxifen, and the first sign is generally heavy bleeding, before or after menopause. “Hemorrhagic” bleeding, 4 DNCs, an IUD, etc, and finally a hysterectomy.

  8. Lucy Stimmel

    Thank you all for this information. My mother never told anyone her diagnosis, but given this information, I can be sure this is what killed her. Thank you.

  9. Cindy

    I experienced post-menopausal bleeding after 4 yrs. of menopause. My bleeding was not caused by cancer, it was caused by adenomyosis. I also had a enlarged uterus, endometriosis on one Fallopian tube, and new cells were growing in my uterus. After having a D&C, 2 IUD’s (the 1st IUD fell out), and taking norithindrone nothing stopped the bleeding. When I was off the norithindrone for 3 days for gallbladder surgery, the bleeding was again extremely heavy. After 1 1/2 yrs. of bleeding, we decided a hysterectomy would be in my best interest. After my hysterectomy my doctor said, in 35 yrs. of practice, he had never seen a uterus look like mine did, as it was not smooth, and ended up being a teaching moment for those involved with my surgery. I’m glad we made the decision to have a hysterectomy, who knows how long I would continue to bleed.

  10. azure

    Cervical cancer (which may also be identified early due to post-menopausal spotting or bleeding) may be linked to use of biologics. Although few MDs seems to think it’s worth tracking to determine the strength of the link, so that it becomes more possible to get research funding for a study.

  11. Michelle

    Postmenopausal Bleeding can be really scary. If you have any bleeding — even if it’s only spotting — you should see a doctor. She’ll want to rule out serious causes, like cancer.
    Thank you for the insights Kelly

  12. Mitzi Reid

    How does she know that she is post menopausal?
    One year without a period .

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