Published: July 22, 2009 09:42 am      

Treatment necessary for post-menopausal problem

DEAR DR. MONA: I stopped having menstrual periods four years ago and then recently I started to have vaginal bleeding again. Is this normal? I am still young (49) and I assume this is OK. — Janice

DEAR JANICE: This is not normal and you should make an appointment with your physician for an evaluation; what you are having is known as post menopausal bleeding.

If you had no periods for four years you were clearly in menopause since menopause is defined by having no periods for one year. Bleeding after menopause can be due to abnormalities in the cervix, the uterine cavity, or ovarian abnormalities.

First it is important to determine where the blood is coming from. When a post-menopausal woman bleeds from the cervix it is usually due to polyps, atrophy, or cervical cancer. Moving up the canal, bleeding from the endometrial cavity (the uterus) could be caused by endometrial polyps, overgrowth in the lining (proliferative endometrium), fibroids (benign tumors), or endometrial cancer. Even though the names might sound serious, most of these are somewhat routine problems experienced by women after they have reached menopause. Stating that they are routine does not mean they should be ignored, however, since it is important to assure that they are not cancer or pre-cancerous.

Overgrowth of the endometrial lining occurs due to the influence of estrogen, either endogenous (due to either ovarian dysfunction, or conversion of hormones in the fat to estrone, a form of estrogen that stimulates the endometrial lining to grow) or exogenous (in patients who use hormone supplements, or unregulated over-the-counter supplements containing estrogen and progesterone or some medications that might mimic the effect of estrogen).

It is important to emphasize that it is not abnormal for women who are taking hormone supplements (PremPro) for menopausal symptoms to bleed; this is called withdrawal bleeding. Patients who are using continuous hormones may have rare cycles with light bleeding for about four to six months when starting hormones.

So I am assuming you are not taking hormonal supplements, Janice. In this case, your doctor will need to ensure that there are no problems in the uterine cavity. You would typically have this evaluated with an ultrasound, or a dilation curettage (D & C) or hysteroscopy (looking inside the uterine cavity with a small scope usually done under local anesthesia) to examine the uterine cavity and obtain a tissue sample for biopsy. An endometrial biopsy can also be performed without the use of the scope.

The tissue sample will be sent to a lab to determine whether there are any abnormal cells. When this done, a treatment plan is easier to make.

So, Janice, get in to see your doctor; the treatment is really successful if we manage this early.



Dr. Mona Alqulali is a board certified OB-GYN.