Postmenopausal bleeding is defined as any bleeding that occurs more than 1 year after the last menstrual period.8 Cancer is the primary concern in these women and must always be excluded. (More on that, in a bit.)
History may reveal underlying pathology
The initial approach to evaluating abnormal bleeding is a thorough history and physical. Ask about stress, dietary habits, exercise, medications, radiation exposure, visual disturbances, headache, weight loss or gain, galactorrhea, palpitations, abdominal symptoms, jaundice, or excessive hair growth. Your patient’s answers to these questions may point to pathologies that underlie the abnormal bleeding, as listed in TABLE 1.
TABLE 1
Abnormal uterine bleeding: A typology3,5,17,18,22-24,30
| Genital tract pathology |
| Vulva Cancer Lichen sclerosis Sexually transmitted diseases (STDs) Vagina STDs Trauma Foreign body Cancer Cervix STDs Cervicitis Cancer Uterus Endometritis Hyperplasia Cancer Polyps Leiomyomas |
| Systemic disease |
| Crohn’s disease Von Willebrand’s disease Thrombocytopenia Acute leukemia Advanced liver disease Hyper/hypothyroidism Chronic renal disease Pituitary disease Emotional or physical stress |
| Medication/iatrogenic cause |
| Tamoxifen Corticosteroids Chemotherapy Anticoagulants Warfarin Aspirin Clopidogrel Antipsychotics Hormonal therapy Oral contraceptives Medroxyprogesterone acetate Intrauterine devices Herbal supplement Black cohosh Soy supplements Radiation |
| Dysfunctional uterine bleeding |
| Anovulatory (90%) Hypothalamic suppression Pituitary adenoma Eating disorders Thyroid disorders Adrenal disorders Primary ovarian disorders (such as polycystic ovarian syndrome) Ovulatory (10%) Structural anomalies |
In postmenopausal women, rule out cancer
The initial work-up for a postmenopausal patient should begin with a pelvic examination, followed by an assessment of her endometrial cavity by transvaginal ultrasound (TVUS), saline infusion sonohysterogram (SIS), or biopsy. An SIS, in particular, is often superior to TVUS in screening for anatomic anomalies.10 If a sonogram shows an endometrial thickness greater than 5 mm or the patient has risk factors for endometrial neoplasia, an endometrial biopsy for histologic diagnosis will be needed.11 Risk factors for endometrial cancer include age older than 40, infertility, diabetes mellitus, hypertension, obesity, and estrogen medication. Repeat the sampling if the biopsy is inadequate. If the patient continues to have uterine bleeding, further evaluation with hysteroscopy by a gynecologist should be considered.12-14
Evaluating bleeding in women of child-bearing age
Bleeding in this age group is most often related to pregnancy, so the diagnostic work-up should begin with a urine pregnancy test.3,15 If pregnancy is ruled out, most etiologies in these women are benign, respond to conservative therapy, and can often be managed exclusively by family physicians.
After excluding pregnancy, look for genital tract pathology, including infection, polyps, uterine fibroids, and signs of cancer; iatrogenic causes such as medications or radiation; and systemic illnesses. In teenagers, look for inherited clotting disorders such as Von Willebrand’s disorder. If cervical cancer screening is not up to date, do a Pap smear.16 Cervical dysplasia generally does not cause heavy vaginal bleeding, but can cause postcoital bleeding.17 A complete blood count and a thyroid-stimulating hormone (TSH) level will allow you to rule out anemia, leukemia, thrombocytopenia, and thyroid disorders.11
Dysfunctional uterine bleeding (DUB): A diagnosis of exclusion
Once you have ruled out genital tract pathology, systemic disease, and iatrogenic causes, you are left with a diagnosis of dysfunctional uterine bleeding. DUB occurs most commonly at the onset of regular menstrual cycles or when menstruation is coming to an end during menopause.
The menstrual cycle in a woman with DUB may be ovulatory or anovulatory. Women who have ovulatory cycles usually know the characteristics of their menses and are often aware of minor variations in the timing or flow. A patient with an anatomic problem who has ovulatory cycles will usually present with complaints of menorrhagia.
Anovulatory cycles are more typical, occurring in 90% of patients with DUB.18 In anovulatory cycles, the corpus luteum is not produced and the ovaries do not secrete progesterone. In the absence of progesterone, constant estrogen stimulation produces a proliferative endometrium that is not sustainable. As 1 area of bleeding heals, another site begins to slough, and the result is an irregular and prolonged bleeding pattern that is unpredictable. The clinical result in this scenario is varying cycle lengths and differing amounts of menstrual blood loss.
Treatment depends on the etiology
Cervical and endometrial cancer should be ruled out early, because early diagnosis and treatment may improve survival. If the source of abnormal bleeding is an anatomic abnormality such as an endometrial polyp, removing the polyp under hysteroscopic guidance should alleviate the problem. If the bleeding is due to medication exposure or a systemic disease such as hypothyroidism, withdrawing the off ending agent or treating the systemic disorder will generally alleviate the problem.