Other benign causes of bleeding include atrophic vaginitis and endometrial and cervical polyps, which may become apparent as postcoital bleeding or spotting. Women who experience bleeding after menopause may attempt to minimize the extent of the problem; they may describe it as “spotting” or “pink or brownish discharge.” However, any indication of bleeding or spotting should be evaluated. In the absence of hormone therapy, any bleeding after menopause (classically defined as absence of menses for 1 year) should prompt evaluation with endometrial sampling. Studies of transvaginal ultrasonography revealing an endometrial thickness 4 mm or less correlate with a low risk of endometrial malignancy, and thus endometrial sampling is not required (250). Endometrial polyps and other abnormalities can be seen in women who are taking tamoxifen. These polyps are more likely to involve cystic dilation of glands, stromal condensation around the glands, and squamous metaplasia of the overlying epithelium (251). These polyps can be benign, although they must be distinguished from endometrial malignancies, which may occur when taking tamoxifen. The incidence of endometrial polyps not associated with tamoxifen increases with age during the reproductive years; it is not clear whether the incidence subsequently peaks or decreases during the postmenopausal years (162). Endometrial polyps are more likely to be malignant in postmenopausal women, and hypertension is associated with an increased risk of malignancy (252).
Endometrial, cervical, and ovarian malignancies must be ruled out in the presence of post-menopausal bleeding. One series found a malignancy (endometrial or cervical) in approximately 10% of women with postmenopausal bleeding (253). A Pap test is essential when postmenopausal bleeding is noted, although the Pap test is an insensitive diagnostic test for detecting endometrial cancer. The Pap test results are negative in some cases of invasive cervical carcinoma because of tumor necrosis.
Cervical malignancy is diagnosed by cervical biopsy of grossly visible lesions and colposcopically directed biopsy for women with abnormal Pap test results (see Chapter 19). Functional ovarian tumors may produce estrogen and lead to endometrial hyperplasia or carcinoma, which may cause bleeding.
Diagnosis of Postmenopausal Abnormal Bleeding
Pelvic examination to detect local lesions and a Pap test to assess cytology are essential first steps in finding the cause of postmenopausal bleeding. Pelvic ultrasonographic examination and, in particular, transvaginal ultrasonography or sonohysterography can suggest the cause of bleeding (250,254). Endometrial sampling, through office biopsy, hysteroscopy, or D&C, is usually considered essential. An endometrial thickness of less than 5 mm measured by transvaginal ultrasonography is unlikely to indicate endometrial cancer, although some authors suggest that the diagnostic accuracy is overestimated and recommend a cutoff of 3 mm (250,255).
Management of Postmenopausal Abnormal Bleeding
Benign Disorders The management of bleeding caused by atrophic vaginitis includes topical (vaginal) or systemic use of estrogens after other causes of abnormal bleeding are excluded. Such therapy can provide significant benefits in terms of quality of life, but must be weighed with each individual, considering contraindications and patient preferences (256,257). Serum levels appear to be lower with vaginal administration using creams, tablets, or rings (258). Cervical polyps can easily be removed in the office.