Is spotting after menopause normal?

Menopause is defined as twelve consecutive months without menstrual periods, normally at age 49-51. At this time, the ovaries stop releasing eggs, and hormone levels plummet. By definition, no further bleeding can occur. Due to this, any spotting or bleeding from the vagina following menopause may be indicative of something wrong, and must be evaluated by a doctor immediately.

Understanding vaginal bleeding

The most common individual cause of bleeding after menopause is vaginal and uterine atrophy due to waning oestrogen levels. When the uterine and vaginal lining are thin and dry after being thinned out, the vagina and uterus are susceptible to irritation and bleeding. This is harmless and can be cured, but it is not the only reason for spotting. Infections, polyps, fibroids, or drug effects of hormone replacement therapy and tamoxifen (a selective oestrogen receptor modulator) are also common offenders.

However, the main reason physicians ask for postmenopausal bleeding to be checked right away, is because of the risk of cancer. Studies have shown that a mere 10% of women presenting with postmenopausal bleeding actually harbour endometrial or cervical cancer; however, in more than 90% of endometrial cancer patients, vaginal bleeding is a symptom. Due to this reason alone, any bleeding occurring after menopause must never be ignored.

Medical causes apart, there may be lifestyle-related causes as well. Smoking, heavy alcohol use, obesity, and uncontrolled diabetes can stimulate inflammation, thin the uterine endometrium, and cause bleeding. Importantly, these lifestyle precipitants are reversible. Smoking cessation, better control of diabetes, restriction of alcohol intake, and maintaining a healthy weight not only reduce the risk of abnormal uterine bleeding, but also improve overall health and well-being in the postmenopausal age group.

Diagnosis and treatment

Despite these facts, spotting in the postmenopausal period is commonly neglected. Most women think that a tiny trickle of blood cannot do any harm, or attribute it to irritation. Some dismiss it as a side effect of hormone replacement, while others are too embarrassed to go to a gynaecologist for bleeding that seems inconsequential. In a few cases, fears of investigation or diagnosis deter women from seeking timely care. Such delays can allow a more serious condition such as cancer to progress uncontrolled.

If a woman has postmenopausal bleeding, the initial medical workup is straightforward. A medical history is taken and a pelvic exam performed. The uterine lining thickness is measured via an ultrasound. If the lining is abnormal, then an endometrial biopsy would be performed to exclude malignancy. These are quick, non-invasive, and informative procedures. Even a single episode of spotting should be followed up, as the sooner the spotting can be detected, the better the treatment and reassurance will be.

Awareness is key

It is vital to remember that while most causes of postmenopausal spotting are not of a serious nature, the symptom in itself must never be overlooked. Education and awareness are the solutions. By understanding that even small postmenopausal bleeding is a sign that should be looked into, women can take matters into their own hands and seek assistance early. Shattering the myth that such bleeding instances are a trivial issue and overcoming the resistance to see a doctor can be matters of life and death.

Finally, remember that postmenopausal spotting is abnormal and should always be explored. The majority of causes are reversible: most benign conditions are readily treatable once discovered and lifestyle-related causes can be reversed. Alternatively, a minority of these cases can reveal more serious diseases, such as endometrial cancer, and this is where early detection has its pay-off. Acting quickly provides reassurance, and also safeguards long-term health and quality of life.

(Dr. Esha R. Shanbhag is associate consultant, gynaecological oncology, Aster Whitefield, Bengaluru. eshars@gmail.com)