Menopause & perimenopause

Post-menopausal bleeding — what does it mean?

by Marcy Holmes, NP, Certified Menopause Clinician

Topics covered in this article:

• Why does post-menopausal bleeding happen?
• Common causes of post-menopausal bleeding
• What should a woman do about bleeding in post-menopause?
• What is an endometrial biopsy?
• What happens after the endometrial biopsy?
• Can a woman prevent post-menopausal bleeding?
• Post-menopausal bleeding and bioidentical hormones
• The best protection for post-menopause issues is information

If you begin to bleed again after reaching menopause — having gone a full year without a period or bleeding — it can be a confusing and somewhat frightening occurrence. But it is a more common occurrence than you think.

Many women come to our clinic or write to us at the Personal Program asking what they should do when they suddenly get what seems to be a period or have some spotting after not having any for over a year. “Does it mean something is wrong?,” “Is this a cause for concern?,” “Am I going to resume monthly periods again?” are all very common questions we receive. (If it’s been less than a year since your last period, you are not yet post-menopausal. For information on irregular bleeding during the years leading up to menopause, read our articles on menstruation and irregular periods.)

Most of the time there is a reasonable explanation for a post-menopausal bleeding event, but any kind of irregular bleeding — particularly if you haven’t had a natural period for over a year — warrants investigation by your healthcare provider — just to rule out anything serious. Like so many symptoms that occur at this time of life, post-menopausal bleeding is often related to the same lifestyle issues that contribute to weight gain, emotional stress, and hormonal imbalance. Sudden spotting or bleeding that is benign is your body’s way of telling you to inventory the demands in your life and the support you are giving yourself.

Let’s talk about the many causes of post-menopausal bleeding and the evaluation process you can expect in follow-up.

Why does post-menopausal bleeding happen?

Any time a woman has gone 12 successive months with no period and then bleeds again — no matter how slight or brief — the flow is considered to be post-menopausal bleeding. Up to 20–30% of menopausal women experience this.

While it is far more common to experience post-menopausal bleeding due to shifting hormones, the less likely scenario is that abnormal cells are developing in the uterus. This can be a symptom of a minor abnormality like hyperplasia of the uterus, or of the more severe issue of uterine cancer. The good news is that all of these scenarios are highly treatable. But it is crucial for the woman whose situation needs more intervention to be identified as early as possible.

More often than not, proper evaluation of post-menopausal bleeding concludes there is nothing for the patient to worry about and no further intervention is needed. At Women to Women, we see benign post-menopausal bleeding result from the use of new or different HRT, nutrient deficiencies, drastic weight loss, extreme stress, or emotional trauma. But the only way to know for sure, and to rest easy, is to have a proper evaluation.

Common causes of post-menopausal bleeding

• Hormonal imbalance

Hormonal change or rebalancing is one of the primary reasons for post-menopausal bleeding. Women changing, adding, or weaning off their HRT may experience unexpected bleeding events. Any woman with a preexisting build-up of tissue inside the uterus may initially experience new spotting after initiating any kind of progesterone or progestin therapy, including the popular low-dose progesterone creams. This does not mean the cream caused the bleeding, but rather allowed the uterus to shed the build-up that was already there.

• Nutrition and insulin resistance

Nutrients support the cycle of hormonal balance, so if you’ve been deficient in certain nutrients over the years it will manifest at menopause in the guise of physical symptoms — like bleeding. One of the best natural ways for post-menopausal women to support their evolving hormonal balance is to clean up their diet and add a high-quality daily multivitamin.

Optimal nutrition, which includes EFA’s and other essential nutrients, is especially relevant for post-menopausal women who are insulin resistant (for many women, the two go hand-in-hand). Many insulin resistant women tend to be highly estrogenic, converting any mobilized progesterone into estrogen. The ratio of estrogen to progesterone is thrown off, which can lead to a number of symptoms and conditions, including weight gain and unusual bleeding. One thing is for sure, these women see huge improvement when they begin a program of rich nutrition, daily exercise and watch their intake of processed sugar, fats, and simple carbs.

• Weight loss

Post-menopausal bleeding may also occur with a drastic weight loss and reduction in body fat, which I have seen on occasion with my own patients. Dramatic weight loss can occur when women have gastric by-pass surgery or join an assertive program like Food Addicts Anonymous (FAA) or Overeaters Anonymous (OA). What’s happening here is that estrogen stored in fat tissue becomes liberated into the bloodstream as a woman loses weight. Bleeding may also occur with weight loss as estrone (E1, one of three main types of estrogen naturally occurring in the body), which relies largely on fat as its source, is reduced as weight loss occurs, resulting in a shift in the relationship between estrogen and progesterone. This rebalancing of hormones, among other health reasons, is why we say gradual weight loss is usually best.

• Emotional stress

Bleeding after menopause can also occur during a particularly stressful or emotional event or due to an unexpected spurt of hormones. I have known some menopausal women to menstruate again when their daughter comes home from college for the summer. I have also known many women in times of extreme grief or anxiety who experience such spontaneous bleeding events. For example, we evaluated an unbelievable number of dysfunctional and post-menopausal bleeding cases in the six months following 9/11. I have not seen that high an incidence of bleeding events since.

What should a woman do about bleeding in post-menopause?

First of all, you should know that any post-menopausal bleeding is considered to be abnormal until proven otherwise (think “better safe than sorry”). This approach is a standard of care in mainstream gynecology for good reason; we would hate to miss the early identification of abnormal uterine tissue, precancerous tissue, or even overt cancer of the uterus.

Early identification is key here because it saves lives; most uterine abnormalities are easily treatable without major consequence. Some cases are serious and may need prompt attention by a skilled GYN cancer specialist, but certainly not all cases of postmenopausal bleeding or abnormal tissue mean cancer. What would be most unfortunate is for a woman to delay an evaluation out of fear that the bleeding might mean something bad.

That is why it is important to make an appointment to see your healthcare provider promptly if you have any bleeding or spotting after a full year without a period. The standard of care for this situation is a bimanual pelvic examination, Pap smear if due, and an endometrial biopsy as soon as possible. Occasionally a practitioner may find the bleeding is not from the uterus, but from a tear in the vaginal wall or from the urethra (the tube-like passageway through which we urinate). Many practitioners will also order an ultrasound to gauge the thickness of the uterine wall and lining and to verify that the ovaries and fallopian tubes look normal.

What is an endometrial biopsy?

This is the first step in a proper evaluation of the intrauterine tissue, often necessary when postmenopausal bleeding occurs. It is a relatively simple procedure that can usually be done in the gynecologist’s office. It is also sometimes done for certain types of abnormal Pap tests.

The endometrial biopsy is performed using a small sterile pipelle, or straw, that passes through the cervix into the uterus. It allows for a sweeping of the inner lining of the uterus and the collection of a small sample of tissue, which is then sent to a lab for evaluation. I like to describe it as something like a deep Pap test; it takes a bit longer and can cause some crampy discomfort, but it is relatively easy to perform and well-tolerated by most women.

If you are having an endometrial biopsy, you may want to take a higher than normal dose of an NSAID like ibuprofen or naproxen the night before, then another dose an hour before the biopsy. Some women benefit from Valium or a mild muscle relaxant like Flexeril, which can reduce tension and help the cervix and uterine muscles relax, allowing the pipelle to be inserted with ease. Just as in labor and childbirth, a woman’s overall tension level affects the muscles of her uterus and cervix and can sometimes pose a challenge in the process. At our office we try to prepare a woman with deep breathing exercises and visualization, and we also apply some reflexology to encourage the cervix to relax.

Endometrial biopsy is a standard of care and generally safe, but there is a slight risk for complications — as with any procedure. Cramps and light spotting may occur. It is wise for a woman to refrain from putting anything in the vagina for 72 hours after an endometrial biopsy, to prevent infection. She should also report any severe pain, fever, discharge, or unusual bleeding to her doctor promptly.

What happens after the endometrial biopsy?

A pathologist will evaluate the tissue sample obtained during the endometrial biopsy and classify it according to a standardized grading system, then notify your healthcare provider of the results. The results of your endometrial biopsy will dictate the protocol most appropriate for you in follow-up. Features of the ultrasound may inform your care, as well.

Some women need a D&C, others may need three to four months of progesterone therapy to reverse tissue growth. Others may require nothing more than a wait-and-see approach, with further steps only if the bleeding recurs or worsens. A few women may need more aggressive treatment options, possibly a hysterectomy or additional intervention. But whatever the results of the biopsy, the information will allow you to act as your own best advocate. If you are not comfortable with the results of the initial evaluation or recommended treatment plan, then go for a second opinion, and even a third — your peace of mind is worth it!

Can a woman prevent post-menopausal bleeding?

In some cases, this kind of bleeding is inevitable. But for most hormonally related bleeding events, maintaining an appropriate weight, and engaging in healthy lifestyle, dietary and stress reduction habits will help. Preventing or minimizing a predominance of estrogen in the years before and after menopause is likewise helpful. This can be facilitated through gentle endocrine support, improved nutrition and supplementation, and reducing stress and exposure to xenoestrogens.

I encourage my patients to look at their post-menopausal bleeding as inspiration to devote themselves to some serious self-care:

• The first step, always, is to call your practitioner and make an appointment for an evaluation.
• The second step is to clean up your diet, add some high quality nutrients and exercise daily for better nutrition and weight control. This can be done immediately and simultaneously with your evaluation.
• The third step is to try some progesterone support if your evaluation indicates it’s okay.

In my experience, these simple steps will go a long way toward preventing future bleeding events.

It’s important to keep one additional thing in mind: We do know from scientific studies that the more adipose tissue (fat) a woman has on board, the greater her statistical risk for the precancerous thickening of the uterus called hyperplasia and some types of uterine cancer. It’s likely that excess body fat both generates excess estrogen and stores estrogen and estrogen-mimicking compounds, all of which overstimulates the uterine lining over the years. So gradually losing that weight is an important step toward balancing your hormones and wellness. Our Personal Program is a great option to consider for women who need help with weight and hormone balance. (See also our health topics on natural weight loss.)

Post-menopausal bleeding, HRT, and supplemental progesterone

Another known risk factor for uterine cancer is the use of systemic estrogen therapy. This is generally true for any kind of estrogen, even bioidentical forms like estradiol. However, every woman is different and so is her ability to handle HRT. These are conversations best had with a trusted healthcare practitioner, one who takes the time to know your history and to listen to all your concerns and symptoms. If you are on HRT or bioidentical hormones, make sure you get your hormone levels checked regularly. Play an active role in your own care.

The progesterone component in HRT is meant to protect a woman from the increased risk, but nothing is 100% guaranteed. So if you are using HRT and still have your uterus, you need to be sure your prescription contains enough progesterone to oppose your estrogen exposure. This is particularly a concern when women choose to take custom-compounded bioidentical hormone replacement therapy.

The reason for this is a key point in the debate about custom-compounded bioidentical HRT: the products themselves and absorption rates may vary, and the blood levels needed for protection have not yet been firmly established. There are some standard gynecological rules pertaining to the minimum doses of progesterone needed when used in conjunction with prescription estrogen therapy, but it is hard to monitor individual bioidentical compounds unless you are working with a medical professional. If you are on bioidentical or any other form of HRT, ask your practitioner what the formula is and be sure to get your blood levels checked regularly. We check our bHRT patients twice a year.

The best protection for post-menopause issues is information

Just as we try to advise all women in perimenopause to report any new, heavy or irregular bleeding, we also want post-menopausal women to report any new or resumed bleeding. We know the prospect of an evaluation can be worrisome, but in the long run, isn’t it better to know what’s really going on?

Luckily, when it comes to post-menopausal bleeding, there is so much you can do — once you have the information in hand. So interpret any surprise bleeding event as a call to action and contact your practitioner for an evaluation. Then you can take the necessary steps to get your hormones back in balance.

Related to this article:

References & further reading on post-menopausal bleeding

 

Original Publication Date: 08/16/2006
Last Modified: 02/16/2010
Principal Author: Marcy Holmes, NP