Tuesday, February 28, 2012

14 Common Causes for Post Menopausal Bleeding

What is post menopausal bleeding?

Post menopausal bleeding occurs when a woman of menopausal age has had 12 months without a period (amenorrhoea) and then has unscheduled (i.e. without hormonal treatment intervention) vaginal bleed. It can be a very frightening and confusing experience, but few people realize how common post menopausal bleeding actually is; it affects as many as 30% of post menopausal women.

Post menopausal bleeding can occur for a number of reasons, the most common of which is hormone replacement therapy. The supplemental hormones used in this kind of treatment stimulate the uterine lining in the same manner as would the natural hormones found in a healthy pre-menopausal female. The frequency and amount of bleeding will vary from woman to woman, but adjusting the dosage of the hormone replacement treatment is usually all that is required to alleviate the bleeding.

There are many other reasons why a woman would experience post menopausal bleeding when not undergoing hormone replacement therapy. Around 90% of these cases will have no obvious cause, or prove to be caused by a minor problem, often not requiring treatment.

However, do not consider even a little spotting as normal after menopause. It is not. If you have postmenopausal bleeding, be sure to make an appointment to see your doctor as soon as possible. While in most cases, it does not indicate a health related issue, it still could be an early indication of particular health related problems, some of which are serious. Better be safe than sorry!

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What is the concern with post menopausal bleeding?

For the majority, there is an innocent cause for the bleeding. However, the most common presenting symptom of an endometrial cancer is post menopausal bleeding. Postmenopausal bleeding should always be taken seriously even if it amounts to no more than a small blood stained discharge. Note that even when the bleeding is related to cancer, if it is diagnosed early there is a very good chance that the disease can be cured.

What are the general causes of post menopausal bleeding - PMB?

  1. Hormonal imbalance. Hormonal change or rebalancing is one of the primary reasons for post-menopausal bleeding. Women changing, adding, or weaning off their HRT may experience unexpected bleeding events. Any woman with a preexisting build-up of tissue inside the uterus may initially experience new spotting after initiating any kind of progesterone or progestin therapy, including the popular low-dose progesterone creams. This does not mean the cream caused the bleeding, but rather allowed the uterus to shed the build-up that was already there.
  2. Nutrition and insulin resistance. Nutrients support the cycle of hormonal balance, so if you’ve been deficient in certain nutrients over the years it will manifest at menopause in the guise of physical symptoms — like bleeding. One of the best natural ways for post-menopausal women to support their evolving hormonal balance is to clean up their diet and add a high-quality daily multivitamin. Optimal nutrition, which includes EFA’s and other essential nutrients, is especially relevant for post-menopausal women who are insulin resistant (for many women, the two go hand-in-hand). Many insulin resistant women tend to be highly estrogenic, converting any mobilized progesterone into estrogen. The ratio of estrogen to progesterone is thrown off, which can lead to a number of symptoms and conditions, including weight gain and unusual bleeding. One thing is for sure, these women see huge improvement when they begin a program of rich nutrition, daily exercise and watch their intake of processed sugar, fats, and simple carbs.
  3. Weight loss. Post-menopausal bleeding may also occur with a drastic weight loss and reduction in body fat, which I have seen on occasion with my own patients. Dramatic weight loss can occur when women have gastric by-pass surgery or join an assertive program like Food Addicts Anonymous (FAA) or Overeaters Anonymous (OA). What’s happening here is that estrogen stored in fat tissue becomes liberated into the bloodstream as a woman loses weight. Bleeding may also occur with weight loss as estrone (E1, one of three main types of estrogen naturally occurring in the body), which relies largely on fat as its source, is reduced as weight loss occurs, resulting in a shift in the relationship between estrogen and progesterone. This rebalancing of hormones, among other health reasons, is why we say gradual weight loss is usually best.
  4. Emotional stress. Bleeding after menopause can also occur during a particularly stressful or emotional event or due to an unexpected spurt of hormones. There are some known cases for menopausal women to menstruate again when their daughter comes home from college for the summer, or for the extreme grief or anxiety.
  5. Polyps. Cervical and endometrial polyps are the growths, usually noncancerous, that can develop in the uterus, on the cervix, or inside the cervical canal, and may cause bleeding.
  6. Endometrial atrophy (thinning of the endometrium). The endometrium, the tissue that lines the uterus, can become very thin after menopause because of diminished estrogen levels, and may cause unexpected bleeding.

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  1. Endometritis. Endometritis is inflammation of the endometrial lining of the uterus. In addition to the endometrium, inflammation may involve the myometrium and, occasionally, the parametrium.
  2. Atrophic vaginitis. Atrophic vaginitis also known as vaginal atrophy occurs when the lining of the vagina atrophies and thins because of the loss of normal estrogen made by the woman’s body. It is considered as the most common cause for the post menopausal bleeding. Generally there are two states of this condition: 1) asymptomatic atrophy of the vaginal walls, and 2) symptomatic atrophic vaginitis or inflammation of the vaginal walls. While they are the same condition the when the condition becomes symptomatic this can be for a number of reasons 1) severe loss of estrogen and 2) secondary infection caused by yeast (candida) overgrowth or bacterial infection secondary to a host of opportunistic bacteria that are normally in or around the vagina but start to overgrow because of injury or inability of the vagina to defend itself.
  3. Endometrial hyperplasia. In this condition, the lining of the uterus becomes thick, usually as a result of too much estrogen and too little progesterone, and bleeding may occur as a result. Some patients with endometrial hyperplasia may have abnormal cells that can lead to endometrial cancer (cancer of the uterine lining).
  4. Urethral caruncle. Urethral caruncles, which often originate from the posterior lip of the urethra, may be described as fleshy outgrowths of distal urethral mucosa. They are usually small but can reach 1-2 cm in diameter. Most urethral caruncles are asymptomatic; however, some may be painful, and others may be associated with dysuria. Larger necrotic lesions may bleed. Some caruncular lesions may look like urethral carcinoma.
  5. Endometrial cancer (uterine cancer). Bleeding after menopause can be a sign of endometrial cancer. Endometrial cancer is the most common type of uterine cancer. Although the exact cause of endometrial cancer is unknown, increased levels of estrogen appear to play a role. Estrogen helps stimulate the buildup of the lining of the uterus. Studies have shown that high levels of estrogen in animals result in excessive endometrial growth and cancer. Most cases of endometrial cancer occur between the ages of 60 and 70 years, but a few cases may occur before age 40.
  6. Ovarian cancer. Ovarian cancer is cancer that starts in the ovaries, the female reproductive organs that produce eggs. The cause is unknown. The risk for developing ovarian cancer appears to be affected by several factors. The more children a woman has and the earlier in life she gives birth, the lower her risk for ovarian cancer. Certain genes (BRCA1 and BRCA2) are responsible for a small number of ovarian cancer cases. Women with a personal history of breast cancer or a family history of breast or ovarian cancer have an increased risk for ovarian cancer. Older women are at highest risk. About two-thirds of the deaths from ovarian cancer occur in women age 55 and older. About 25% of ovarian cancer deaths occur in women ages 35 - 54.
  7. Cervical cancer. Cervical cancer occurs when abnormal cells on the cervix grow out of control. The cervix is the lower part of the uterus that opens into the vagina. Cervical cancer can often be cured when it's found early.
  8. Other causes. Other, not listed causes might include infection of the cervix, abnormalities in the fallopian tube or ovary, use of certain medications, such as blood thinners, and other types of cancer, which can also cause postmenopausal bleeding in some cases.

Occasionally, haematuria (blood in the urine) or rectal bleeding may mistakenly present as "post menopausal bleeding".

Women frequently present to their gynecologist with a period-like bleed when they have previously fulfilled the criteria for the menopause. Premenstrual type symptoms such as breast discomfort may have preceded the bleeding. Appropriate clinical examination and investigation is imperative. Once a pathological (disease) cause for the bleeding has been excluded, it would seem logical to conclude that the woman might have been correct in her belief that she had experienced menstruation again. Presumably this must have followed maturation of an egg which was scheduled to occur a year or more after the previous period.

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