Postmenopausal vaginal bleeding
Postmenopausal bleeding is bleeding that occurs after menopause. Menopause is a stage in a woman’s life (around age 51) when reproductive hormones drop and her monthly menstrual periods stop. Vaginal bleeding that occurs more than a year after a woman’s last period isn’t normal. The bleeding can be light (spotting) or heavy.
The most common causes are endometrial atrophy, endometrial proliferation or hyperplasia, endometrial or cervical cancer, and administration of estrogens without or with added progestin. Other causes include atrophic vaginitis, trauma, endometrial polyps, friction ulcers of the cervix associated with prolapse of the uterus, and blood dyscrasias.
The vulva and vagina should be inspected for areas of bleeding, ulcers, or neoplasms. Cervical cytology should be obtained, if indicated. Transvaginal sonography should be used to measure endometrial thickness. An endometrial stripe measurement of 4 mm or less indicates a low likelihood of hyperplasia or endometrial cancer. If the endometrial thickness is greater than 4 mm or there is a heterogeneous appearance to the endometrium, endometrial sampling is indicated. Sonohysterography may be helpful in determining if the endometrial thickening is diffuse or focal. If the thickening is global, endometrial biopsy or D&C is appropriate. If focal, guided sampling with hysteroscopy should be done.
Simple endometrial hyperplasia calls for cyclic or continuous progestin therapy (medroxyprogesterone acetate, 10 mg/day orally, or norethindrone acetate, 5 mg/day orally) for 21 or 30 days of each month for 3 months. The use of a levonorgestrel intrauterine system is also a treatment option. Repeat sampling should be performed if symptoms recur. If endometrial hyperplasia with atypia or if carcinoma of the endometrium is found, hysterectomy is