Although a little spotting may seem harmless enough, any vaginal bleeding that occurs after menopause should be evaluated immediately by your physician. Here are some possible causes of postmenopausal bleeding (listed from most to least common):
Menopausal hormone therapy (HT). If you’re taking hormone replacement pills, you may experience light cyclic bleeding similar to a menstrual period. This bleeding, called withdrawal bleeding, may occur in any regimen in which progestin is taken for only part of the month. In time, this bleeding tapers off and may eventually end.
For the first few months of HT, breakthrough bleeding may also occur. But your doctor can adjust your dosage to eliminate it.
Cancer. Up to 25 percent of postmenopausal bleeding is caused by a cancer of the reproductive organs. Endometrial cancer (at times called uterine cancer) is the most common. Most often diagnosed in women between 55 and 60 years old, endometrial cancer usually is treated by a complete hysterectomy and radiation. If caught early, endometrial cancer can be treated successfully 90 percent of the time.
In rare cases, postmenopausal vaginal bleeding may also be a sign of vulvar, vaginal, cervical or ovarian cancer.
Atrophic vaginitis. When estrogen levels decrease at menopause, the lining of the vagina thins. Intercourse can injure the delicate tissue, which may bleed as a result. A vaginal cream or ring that contains estrogen usually fixes this problem. HT in the form of a pill or patch also restores vaginal tissue to a premenopausal state.
Cervical or uterine polyps. A polyp is a protruding growth attached by a stem. Polyps are quite fragile and full of blood vessels, so they bleed easily—especially during intercourse. A single cervical polyp can be removed during a brief office procedure.
If you have several cervical polyps or polyps that grow again after being removed, your doctor may recommend dilation and curettage, or D&C (scraping of the uterine lining). Most D&Cs are done in the hospital with a general anesthetic. Polyps inside the uterus are removed during D&Cs by the scraping itself and by special polyp forceps. At the time of a D&C, hysteroscopy may also be used for polyp removal. A thin telescope-like instrument is inserted through the vagina and cervix into the uterus. Instruments needed to remove the polyps are then slipped through the hysteroscope itself into the uterus.
Uterine Hyperplasia. Also called endometrial hyperplasia, this abnormal increase in the number of cells in the uterine lining is common among women around the time of menopause. While not in itself cancerous, this condition can be a forerunner of uterine cancer. There are three types of hyperplasia: Cystic hyperplasia, which is unlikely to turn cancerous; adenomatous hyperplasia, which may progress to cancer in up to 25 percent of cases; and atypical hyperplasia, which is quite likely to become cancerous. Treatment options depend on your history and may include taking progestin and hysterectomy.
Fibroid tumors. In rare cases, these tumors (which are almost always benign) can cause abnormal bleeding in postmenopausal women. Usually, however, they shrink after menopause, leaving them less likely to cause problems—unless you’re undergoing HT. If your fibroids aren’t causing symptoms, such as bleeding or abdominal pain, and do not press on your abdominal organs, you may not need treatment. If you have troublesome symptoms, your doctor may recommend hysterectomy (removal of the uterus).