Frequently asked questions about post-menopausal bleeding

Dr Tahir Mahmood, Consultant Gynaecologist at The Edinburgh Clinic, answers your frequently asked questions about post-menopausal bleeding.

What is post-menopausal bleeding and when do I need to see a doctor?
The menopause is when your periods permanently stop. This happens because the follicles (small sacs) that release eggs in your ovaries are no longer active.

Before the menopause, it is common to have episodes of irregular bleeding or less frequent periods for several months or years. If you have any bleeding from the vagina more than 12 months after your periods stop altogether, you need to see a doctor.

What causes post-menopausal bleeding?
If you have post-menopausal bleeding, the lining of your womb called the endometrium is examined. It is important to exclude any pre-cancerous changes or womb cancer.

The risk of womb cancer increases with age. Womb cancer is more common after the menopause, although about 25% of cases affect individuals before the menopause in a high risk group. Any post-menopausal bleeding is unlikely to be caused by womb cancer, but it is always best for a doctor to check. When diagnosed early, womb cancer can often be cured.

Post-menopausal bleeding can also be caused by conditions affecting other parts of the body. These include the cervix (entrance to the womb), vagina, vulva (outer part of the female genitals) and urinary or digestive tracts. Your doctor carefully considers all possibilities.

Potential causes of post-menopausal bleeding include:

Bleeding from the vulva and the vagina

• Non-cancerous (benign) areas of abnormal tissue called lesions on the vulva
• Pre-cancerous and cancerous changes in the vulva
• Vaginal dryness
• A foreign body in the vagina

Bleeding from the cervix

• Pre-cancerous or cancerous changes in the cervix
• Small growths that are usually non-cancerous called polyps in the cervix

Urinary cause of bleeding

• An abnormal area of tissue at the opening of the urethra (the tube that carries urine out of the body)
• An abnormal area of tissue in the bladder

Bleeding in the digestive tract

• Lumps called haemorrhoids inside and around your bottom (anus)
• A small tear called an anal fissure in the lining of the anus
• A condition called diverticulitis, where small, bulging pouches develop in your digestive tract and become inflamed or infected
• Inflammatory bowel disease, where your digestive tract becomes inflamed
• Cancer of the colon (large intestine)

What is the risk of getting womb cancer?
Anyone with a womb can get womb cancer. This includes women, trans men, non-binary people and intersex people who have a womb.

The risk of getting womb cancer ranges from 5.7% to 11.5%. There are a few things that can increase the risk:

• Age: The risk of womb cancer increases as you get older. About 6 to 8 in every 100,000 women over the age of 50 are diagnosed with womb cancer each year. About 13% of women over the age of 60 with post-menopausal bleeding have womb cancer.
• Hormone replacement therapy: Some people have hormone replacement therapy (HRT) to relieve the symptoms of the menopause. There are different types of HRT. If you have a type that contains the hormone oestrogen only, this increases the risk of womb cancer by about five times. Oestrogen makes the lining of the womb get thicker and cancer cells can then start to grow. You are normally only prescribed this type of HRT if have already had an operation to remove your womb (a hysterectomy).Combined HRT contains the hormones oestrogen and progesterone. It is thought that progesterone balances the effects of oestrogen on the body. The increased risk of womb cancer is not completely eliminated if you have combined HRT. However, this risk is quite low. Women on combined HRT often have irregular bleeding. If the bleeding continues for more than six months, this needs to be investigated.
• Taking Tamoxifen: Tamoxifen is a hormone therapy drug used to treat some types of breast cancer. It seems to have a similar effect to oestrogen on the womb and can increase the risk of womb cancer by about 10%. The risk depends on how much Tamoxifen you take (the dose) and for how long. Usually, the benefit of taking Tamoxifen as part of breast cancer treatment outweighs the small risk of womb cancer.
• Family history: If you have a family history of breast or ovarian cancer, this may increase your risk of womb cancer. Some people inherit a faulty gene that causes a rare condition called Lynch syndrome. This condition is linked with a higher risk of some cancers, including womb cancer. Women with the faulty gene have an estimated 42% to 60% chance of getting womb cancer during their lifetime. The cancer typically develops in the years before the menopause.
• Being overweight: Women who are overweight generally have higher levels of oestrogen in the body. Fatty tissue produces extra oestrogen, which can increase the risk of womb cancer.
• Other factors: You may be more likely to get womb cancer if you have never given birth or went through the menopause after the age of 55. Other medical conditions may also increase the risk of womb cancer. These include high blood pressure, diabetes and conditions associated with a higher level of oestrogen in the body.

If I have post-menopausal bleeding, what tests do I need?
At The Edinburgh Clinic, we can perform various tests to find out what is causing your bleeding and plan any treatment. These tests may include:

• An examination of your pelvis and cervix (lower part of the womb): We examine your pelvis (the lower part of your tummy) in detail. This includes gently putting a plastic device called a speculum into your vagina to hold it open and inspect the cervix. We can then confirm whether the bleeding is coming from the womb. It is important to rule out any other possible bleeding from the lower genital tract (the cervix, vagina, vulva or urethra).
• Transvaginal ultrasound scan: You have this scan in the X-ray Department and do not need an anaesthetic. We gently put a small device called an ultrasound probe into your vagina. The probe sends pictures of the womb lining and both ovaries to a monitor. If the womb lining is thicker than 4 to 5mm and looks suspicious, you need more tests.
• Hysteroscopy and biopsy: A hysteroscopy is a procedure to examine the inside of your womb. You do not have to stay in hospital overnight and may not need an anaesthetic. Sometimes, a local anaesthetic is used to make the area numb. In other cases, you may have a general anaesthetic that sends you to sleep for a short time.

We pass a narrow tube called a hysteroscope into your womb through the vagina and cervix. This tube has a light and camera at the end. It sends pictures of the inside of your womb to a monitor. We can also see any other structures, such as polyps or small fibroids (non-cancerous growths).

During a hysteroscopy, we can take a small sample of tissue for testing. This procedure is called a biopsy. We send the sample to a laboratory, which checks the tissue for any pre-cancerous or cancerous changes.

Sometimes, initial tests such a biopsy may not show any problems. If you still have  episodes of post-menopausal bleeding, we then organise more tests.

What treatments are available for post-menopausal bleeding?
The treatment that you need for post-menopausal bleeding depends on what is causing this bleeding. At The Edinburgh Clinic, we carry out an initial assessment followed by more detailed tests to make an accurate diagnosis.

Your specialist consultant can offer you non-surgical or surgical treatments tailored to your needs. For example, if you have polyps or fibroids, your consultant may remove these growths during a hysteroscopy procedure. If your bleeding is due to vaginal dryness, you may be given an oestrogen cream or pessaries (a small block that is put into the vagina and dissolves).

Surgery is often the main treatment for womb cancer, with or without subsequent chemotherapy and radiotherapy. In Scotland, this treatment is planned at gynaecology cancer centres. Our team can have a discussion with the gynaecology centre and work with them to prepare a personal treatment plan for you.

About Dr Tahir Mahmood
Dr Tahir Mahmood, Consultant Gynaecologist, has wide experience in all areas of women’s health. He has specialist interests in post-menopausal bleeding and hysteroscopy.

To make an appointment with Dr Mahmood at The Edinburgh Clinic, please call 0131 516 4803 or complete an enquiry form here.