Postmenopausal Bleeding

Women have menstrual cycles from the age of 11-12 years to about 50 years. In this time span of 40 years one is likely to have few episodes of bleeding which is not her usual cycle. If his abnormality persists then one needs to become concerned and consult a gynecologist. There may be increase in the number of days of bleeding, there could be heavy bleeding with clots there could be associated pain or the bleeding could be irregular. It is normal for a woman's menstrual bleeding to last up to 7 days. Abnormal bleeding can occur when the menstrual period is not regular, when bleeding lasts longer than normal, is heavier than normal, or when bleeding patterns change. 

What is a normal menstrual cycle?
A normal cycle that comes every 28-35 days lasts for 7-8 days and is not associated with pain or clots. During the menstrual cycle, two hormones -estrogen and progesterone act on the lining (endometrium) of the uterus and causes it to grow. At the end of the cycle this endometrium sheds and this is seen as menstrual bleeding. 
The menstrual cycle begins with the first day of the bleeding of one period (referred as D1) and ends with the first day of the next period. An average cycle lasts about 28 days, but it can be longer or shorter. If the cycle is longer than 35 days or shorter than 21 days, it is considered abnormal. Abnormal uterine bleeding includes:

  • Bleeding between periods
  • Bleeding after sex
  • Spotting anytime in the menstrual cycle
  • Bleeding heavier or longer than normal
  • Absence of menstrual periods for 3 normal cycles or 6 months

Abnormal bleeding can occur at any age. There are times in a woman's life when it is common for periods to be somewhat irregular. Periods often are not regular the first few years after a girl begins to have periods (around 9–16 years of age). Beginning as early as 35 years of age and more commonly when a woman nears menopause (around 50 years of age), it is normal for her menstrual cycle to become shorter. It also is normal for her to skip periods or for bleeding to become lighter. If bleeding becomes heavier, however, it should be checked. 

There are many causes of abnormal bleeding. Some of these problems are not serious and can be easily treated by counseling or medications. Others can be more serious. All should be checked. This can occur when the body makes too much or not enough of a certain hormone. Problems linked to some birth control methods, like intrauterine devices or oral contractive pills can also cause abnormal bleeding. Pregnancy related causes are also responsible for abnormal bleeding. Sometimes tumours in the uterus or even cancer can be the reason. 

To diagnose the cause for abnormal bleeding, a detailed history with physical examination is essential. Additionally few blood tests and an ultrasound examination may be needed to rule out problems in the uterus.  It is helpful to maintain a menstrual calendar because it gives a good insight into the problem if the pattern is available over 4-6 months.  A thyroid test is also important, as abnormality in thyroid hormone secretion can be a cause for abnormal bleeding. Beyond this hysteroscopy (endoscopic evaluation) of the uterine cavity or a D&C may be needed to reach to a diagnosis. Sometimes a laparoscopy is needed to rule out other causes.

Treatment for abnormal bleeding will depend on many factors, including the cause, age, the severity of the bleeding, and whether one desires to have any future pregnancies. It can be treated with hormones or other medications, or surgery may be needed. It takes a few cycles to understand if the medications are working. First line of treatment is non-hormonal medications that help to reduce pain and bleeding when taken during the periods. If it helps you may need to take them during periods for few cycles. Hormones are other medications that maybe needed if there is suggestion of hormonal imbalance of deficiency. Progesterone (one type of hormone) can help prevent and treat endometrial hyperplasia. It may take a few months for hormones to control the bleeding. Your periods may be heavier for the first few months. However, they will lighten over time. 

Some women with abnormal uterine bleeding may need to have surgery to remove growths (such as polyps or fibroids) that are causing the bleeding. This often can be done with hysteroscopy, but sometimes other surgery is needed. Endometrial ablation also is used to treat abnormal uterine bleeding. This treatment uses heat to destroy the lining of the uterus. It is intended to stop or reduce bleeding permanently. An endometrial biopsy is needed before treatment. A woman may not be able to get pregnant after ablation. 
Hysterectomy—removal of the uterus—is another procedure that may be used to treat abnormal bleeding. This may be done when other forms of treatments have failed or are not an option. Hysterectomy is major surgery. After this procedure, a woman will no longer have periods. She also will not be able to get pregnant. 

If you notice that your cycles have become irregular, it is better to consult a gynecologist. Abnormal bleeding has a number of causes. There is no way of telling why your bleeding is abnormal until a gynecologist has made an assessment of your problems. Once the cause is found, abnormal bleeding often can be treated with success.

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