Postmenopausal Bleeding


What is Menopause?

The term menopause is used to describe the end of menstruation. A woman is described to be in menopause if she haven’t had a menstrual period for 12 months. Any bleeding after this period is not normal and should be checked by the gynecologist [1].

What is Postmenopausal Bleeding?

Menopause is a part of the biological process for female and signals the end of the female fertility period. This commonly occurs when a woman is in her 40’s or 50’s. Any spotting or bleeding after the woman becomes menopause is called postmenopausal bleeding. This bleeding is usually a sign of an underlying condition so it should be evaluated to identify the pathologic condition than causes the bleeding [1, 2, 3, 4].

ICD10 of Postmenopausal Bleeding

The 2016 ICD-10-CM diagnosis code utilized for postmenopausal bleeding is N95.0. This code is for any bleeding after the postmenopausal period [5].

Causes of Postmenopausal Bleeding

There are several possible causes of postmenopausal bleeding. Here are some of the most common causes:

Endometrial hyperplasia

The lining of the uterus of a woman with this condition becomes thick and cause bleeding. This condition can be due to being overweight, having high levels of estrogen or undergoing hormonal replacement therapy. It should be treated promptly because it is one of the leading cause of endometrial cancer. Figure 1 shows the difference between a normal endometrium and a thickened endometrium lining [2, 3, 6, 7].


Polyps

Polyps are noncancerous growths that may develop in the cervix and the uterus itself. These polyps may cause mild to severe bleeding especially if they are hit during sexual intercourse [2, 3, 6].

Endometrial atrophy

Decreased level of estrogen in the blood will cause thinning of the uterine lining or endometrial atrophy. This is the most common cause of postmenopausal bleeding accounting for around 60-75% of all the cases [2, 3, 8].

Uterine Cancer

Around 75% of women who are diagnosed with this type of cancer are in the postmenopausal state and bleeding is the most common symptom. Although only around 20% of the cases of bleeding are due to cancer, it is essential to investigate the cause of bleeding so that this diagnosis can be eliminated [2, 9].

Symptoms of Postmenopausal Bleeding

The primary symptom is any degree of vaginal bleeding that occurs at least 12 months the menstrual period have stopped. It may be normal for postmenopausal women who are taking hormone replacement therapy to experience some vaginal bleeding that may be similar to a menstruation for a few days each month but heavy or prolonged vaginal bleeding should be reported to the physician [2, 3].

Women who experience bleeding secondary to endometrial atrophy may experience some pain during sexual intercourse [4].

Diagnosis of Postmenopausal Bleeding

Health History and Physical Examination

During the first consultation, the physician will conduct an analysis of the health history. The family history will be known and any hormone that the patient is taking will be asked as well. Pelvic examination of the cervix, vagina and vulva will be performed in order to rule out any lower genital tract cause. Additional tests will be ordered by the physician to identify the cause of the bleeding [10].


Endometrial Biopsy

In performing a biopsy of the endometrium, a thin tube will be inserted into the uterus and a tiny sample will be obtained and be sent to the laboratory to identify any cellular changes to the endometrium [2].

Transvaginal Ultrasound

The ultrasound device will be inserted into the vagina and it will be able to provide a visualization of the pelvic organs [2].

Hysteroscopy

An instrument with a light and small camera will be inserted into the vagina to be able to examine and look for any changes in the uterus [2].

Treatment of Postmenopausal Bleeding

The recommended treatment for postmenopausal bleeding depends on the identified cause of the bleeding. If cervical polyps is the underlying cause, undergoing surgery to remove these growths will resolve the bleeding. Endometrial atrophy and hyperplasia will be treated through hormone medications. If the bleeding is considered to be a side effect of the hormone replacement therapy, changing or stopping the treatment may be advised by the physician [2, 3, 4].

Postmenopausal Bleeding


If the patient is diagnosed to have a uterine cancer, a total hysterectomy is the best option for the patient. In this procedure, the uterus, cervix and ovaries will be removed to halt the progression of the condition [2, 3, 4].


References

  1. Mayo Clinic. (2015, January 7). Menopause. Retrieved from Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/menopause/basics/definition/con-20019726
  2. (2014, June 28). Postmenopausal Bleeding. Retrieved from WebMD: http://www.webmd.com/menopause/guide/postmenopausal-bleeding?page=2
  3. (2014, August 15). Postmenopausal Bleeding. Retrieved from NHS: http://www.nhs.uk/conditions/postmenopausal-bleeding-or-spotting/Pages/Introduction.aspx
  4. DePietro, M. A. (2015, September 2). Postmenopausal Bleeding. Retrieved from Healthline: http://www.healthline.com/health/postmenopausal-bleeding#Overview1
  5. (2015). 2016 ICD-10-CM Diagnosis Code N95.0. Retrieved from ICD10Data: http://www.icd10data.com/ICD10CM/Codes/N00-N99/N80-N98/N95-/N95.0
  6. The American College of Obstetricians and Gynecologists. (2011, May). Perimenopausal Bleeding and Bleeding After Menopause. Retrieved from The American College of Obstetricians and Gynecologists: http://www.acog.org/Patients/FAQs/Perimenopausal-Bleeding-and-Bleeding-After-Menopause
  7. New Health Advisor. (2014). Thickening of the Womb. Retrieved from New Health Advisor: http://www.newhealthadvisor.com/Thickening-of-the-Womb.html
  8. Morgan, M. (2015). Endometrial atrophy. Retrieved from Radiopedia: http://radiopaedia.org/articles/endometrial-atrophy
  9. Creasman, W. T. (2015, December 4). Endometrial Carcinoma CLinical Presentation. Retrieved from Medscape: http://emedicine.medscape.com/article/254083-clinical
  10. net. (2011, October 7). The Significance of Bleeding after Menopause. Retrieved from ObGyn.net: http://www.obgyn.net/menopause/significance-bleeding-after-menopause

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