For women, reaching menopause can feel like closing a long chapter of monthly cycles and dealing with cramps and all the hassle that comes with periods. So it can be puzzling when bleeding returns months or even years after menopause. Is this a cause for concern?
According to Dr Maina Muriithi, an obstetrician and gynaecologist at Lifecare Group of Hospitals, any bleeding after menopause should be checked by a doctor.
“Menopause does not happen overnight. It is a transition,” he says. "In the years leading up to it — the premenopausal period — a woman’s hormones begin to change." Periods may become irregular, lighter or heavier, or occur less frequently. Symptoms such as hot flushes and vaginal dryness may also appear.”
He adds that a woman is only considered to have reached menopause after 12 consecutive months without any menstrual bleeding.
"The periods may change before they stop completely, and that can be expected. However, if you have not had a period for 12 months and then experience any bleeding, it is abnormal, and you should seek medical attention,” he explains.
"It is not very common, but it does happen." Dr Muriithi says the reassuring news is that around 90 per cent of cases are caused by non-cancerous (benign) conditions.
The most common cause is the thinning of the uterine lining, known as endometrial atrophy. Other causes include polyps and fibroids presenting with bleeding. Other causes include hormone replacement therapy or other oestrogen use.
Sometimes, however, the bleeding may not come from the uterus, but from nearby structures, such as the vagina or urethra.
However, he notes that there is a reason why doctors take postmenopausal bleeding seriously. "Less than 10 per cent of cases of post-menopausal bleeding may be a sign of endometrial cancer, that is, cancer of the lining of the uterus."
“The challenge is that it is impossible to determine the cause solely by examining the symptoms. This is why every woman with postmenopausal bleeding requires an evaluation," he says.
The risk is higher for women who are overweight, smoke, have hypertension or diabetes, or have a family history of reproductive tract cancers.
Dr Muriithi says that bleeding occurring 10 to 15 years after menopause is more likely to be linked to a serious cause than bleeding occurring within the first few years after menopause.
"Any bleeding after menopause is considered a warning sign. But the urgency increases if it is heavy or contains clots, is associated with unusual discharge, or is accompanied by pelvic pain or pressure."
Post-coital bleeding — bleeding during or after sex — should also be assessed. "In menopausal women, vaginal dryness and tissue thinning can cause minor bleeding, but other conditions, such as cervical cancer, must be ruled out," he adds.
A woman's reproductive health system. Menopause typically occurs in women between the age of 49 and 52. FILE PHOTO
He recommends that women have a Pap smear screening every three years from the age of 25 to 65. The evaluation usually follows a step-by-step process. First, the doctor will take a medical history and perform a physical and vaginal examination to check for visible causes, such as polyps or tissue thinning. This will be followed by a pelvic ultrasound to examine the uterus and measure the thickness of the uterine lining.
If the lining appears thickened, a biopsy will be taken in the clinic or theatre using a small camera to collect targeted samples.
However, he says, the treatment depends on the cause. "For atrophy, local oestrogen creams can be used to improve vaginal tissue. If the cause is a polyp or polyps in postmenopausal women, they need to be removed and checked for signs of malignancy. If endometrial cancer or malignancy is found, advanced tests such as an MRI scan are performed to check for any spread and stage the tumour. Most of these tumours of the endometrial lining are captured quite early because we advise all women with postmenopausal bleeding to seek medical attention immediately.”
Unlike most other gynaecological cancers, endometrial malignancies are detected early, and the usual intervention is removal of the uterus, fallopian tubes and ovaries, followed by regular check-ups,” he adds.
“No, it is not a normal part of ageing, nor is it something that every woman experiences. The average age of menopause for African women is around 51 or 52. Menopause before the age of 40 is considered premature ovarian insufficiency, while menopause after the age of 52 is generally not a concern.”|
Regardless of age or timing, however, the rule remains the same: any new bleeding after menopause should be checked. Dr Muriithi emphasises that women using hormone replacement therapy should always inform their doctor, as it can sometimes cause unexpected bleeding.
