Blood clots during menopause

Heavier Flow in Perimenopause

Question

I am 49 and have had a regular light period all my life. I have 3 children and do not use oral contraception. Recently I have been experiencing large clots and heavier flow. It is the clots that concern me because I have never seen this before. Should I seek the help of a gynecologist?

Answer

Thank you for your question. It is quite common for women in perimenopause, which you probably are, to have heavier flow and with that go clots. Often menstrual cramps also increase.

The only worrisome problem about clots and heavier flow is if it means that you are at risk for a low blood count (anemia) because of loss of iron. An indicator of that is use of 16 or more soaked normal-sized pads or tampons in one full period. Often the reason for heavy flow in perimenopause is that estrogen levels are high and progesterone levels are low or the time of progesterone in the cycle (luteal phase) is too short. These hormonal changes also cause the increased cramps.

I’d look at “Very Heavy Menstrual Flow” for some suggestions. If it persists you should tell your doctor, get a blood count and probably start cyclic progesterone therapy.

The good news is that periods and all of the changes of perimenopause will eventually go away and you will graduate into menopause.

Hope this is helpful to you.

Topic: Heavy flow, Progesterone therapy Life Phase: Perimenopause Updated Date: Wednesday, November 20, 2013 – 14:15

What to Expect in Perimenopause

At midlife, women transition from their reproductive years to the natural end of monthly menstrual cycles. This transition — called perimenopause — usually begins in the 40s and ends by the early 50s, although any age from the late 30s to 60 can be normal. It can be difficult to know whether you’ve entered perimenopause, because the hormonal fluctuations begin while menstrual periods are still regular.

Perimenopause can last anywhere from one to 10 years. During this time, the ovaries function erratically and hormonal fluctuations may bring about a range of changes, including hot flashes, night sweats, sleep disturbances, and heavy menstrual bleeding. Other signs of perimenopause can include memory changes, urinary changes, vaginal changes, and shifts in sexual desire and satisfaction.

Some women breeze through the transition. For many others, the hormonal changes create a range of mild discomforts. And for about 20 percent of women, the hormones fluctuate wildly and unpredictably, and spiking and falling estrogen and declining progesterone cause one or more years of nausea, migraines, weight gain, sore breasts, severe night sweats, and/or sleep trouble. For this group, perimenopause can be enormously disruptive both physically and emotionally.

Perimenopause can sometimes be managed through self-help approaches such as meditation, yoga, relaxation, regular exercise, healthful food, enough sleep, and support from family and friends. When perimenopause is particularly difficult, a combination of non-medical and medical solutions may be helpful.

Health care providers who are well informed about perimenopause can be important partners in thinking through the options. This article presents what is known about the risks and benefits of different approaches so you can choose what works best for you.

PERIMENOPAUSAL SIGNS

Premenstrual Syndrome (PMS)

Some women report more severe premenstrual discomforts (PMS) during early perimenopause, when cycles are still regular, such as swollen or tender breasts, water retention (bloating), anxiety, sleep disruption, or irritation.

Whether you have had such discomforts for years or are just beginning to have them now, you can typically look forward to relief later in perimenopause, when your periods become irregular, and certainly by postmenopause, when the hormones level out. (For more information on menstrual discomforts such as mood changes and severe cramps, see Physical and Emotional Challenges Through the Menstrual Cycle.)

Menstrual Cycle Changes

One common menstrual change in early perimenopause is shorter cycles, usually averaging two or three days less than usual but sometimes lasting only two or three weeks. It can feel as though you’re starting a period when the last one has barely ended. In later perimenopause, you may skip a period entirely, only to have it followed by an especially heavy one. Occasionally, menstrual periods will be skipped for several months, then return as regular as clockwork.

The hormonal ups and downs of perimenopause can be the cause of almost any imaginable bleeding pattern. When estrogen is lower, the uterine lining gets thinner, causing the flow to be lighter or to last fewer days. And when estrogen is high in relation to progesterone (sometimes connected with irregular ovulation), bleeding can be heavier and periods may last longer.

Menstrual irregularities are a normal part of this stage in a woman’s life. If you and your health care provider decide that efforts should be made to regulate your cycles at this time, be aware that while oral contraceptives are sometimes prescribed for menstrual irregularities, the use of progesterone alone can be a milder intervention.

Progesterone can be used to manage the imbalance of estrogen and progesterone. A clinician can prescribe progesterone or its synthetic cousins, progestins, to be taken the last 14 days of the cycle. This replaces the progesterone that would normally be secreted in an ovulatory cycle and helps to create a more regular bleeding pattern.

Abnormally Heavy Bleeding

About 25 percent of women have heavy bleeding (sometimes called hypermenorrhea, menorrhagia, or flooding) during perimenopause. Some women’s menstrual flow during perimenopause is so heavy that even supersized tampons or pads cannot contain it. If you are repeatedly bleeding heavily, you may become anemic from blood loss. During a heavy flow you may feel faint when sitting or standing. This means your blood volume is decreased; try drinking salty liquids such as tomato or V8 juice or soup. Taking an over-the-counter NSAID such as ibuprofen every four to six hours during heavy flow will decrease the period blood loss by 25 to 45 percent.

Don’t ignore heavy or prolonged bleeding — see your health care provider if it persists. Your provider can monitor your blood count and iron levels. Iron pills can replace losses and help avoid or treat anemia.

Other medical treatment may include progesterone therapy or the progestin-releasing Mirena IUD, which is known to reduce menstrual bleeding. If your health care provider suggests hysterectomy as a solution to very heavy bleeding during perimenopause, you may want to try other less invasive approaches first. Removal of the uterus is an irreversible step with many effects.

Heavy bleeding during perimenopause may be due to the estrogen-progesterone imbalance. Also, polyps (small, noncancerous tissue growths that can occur in the lining of the uterus) can increase during perimenopause and can cause bleeding. Fibroid growth during perimenopause can sometimes cause heavy bleeding, especially when the fibroid grows into the uterine cavity.

If very heavy bleeding persists despite treatment, your provider should test for possible causes of abnormal bleeding. (Learn more about the causes of abnormal uterine bleeding as well as the pros and cons of various treatment options.)

Hot Flashes and Night Sweats

Hot flashes are legendary signs of perimenopause and for some women can continue well into postmenopause, though 20 to 30 percent of women never have them at all. A woman experiencing a hot flash will suddenly feel warm, then very hot and sweaty, and sometimes experience a cold chill afterward. For detailed information on hot flashes and strategies for reducing discomforts, see Hot Flashes and Night Sweats.

Sleep Disturbances

Many women in both perimenopause and postmenopause experience sleep disturbances. Most commonly, a woman will fall asleep without a problem, then wake up in the early-morning hours and have difficulty getting back to sleep. For detailed information on sleep problems and tips for addressing them, see Sleep Disturbances.

Vaginal Changes

As estrogen and progesterone levels decline in late perimenopause and postmenopause, vaginal walls frequently become thinner, drier, and less flexible and more prone to tears and cracks. This can lead to irritation and difficulties with penetration. For information on how to address these issues, see Dealing with Vaginal Dryness.

For many women, perimenopause can feel a lot like being back in junior high: acne, mood swings, body odor concerns, and … ugh … unpredictable and heavy periods.

Occasional heavy periods (called “menorrhagia”) are common to both puberty and perimenopause, but women in perimenopause generally experience the heaviest flows. One study reported that nearly 78 percent of its 1,300 middle-aged female participants had “three days or more of heavy flow.” Because they’re so common, heavy periods are our symptom of the month.

So, what does “normal” heavy flow look like? How much is too much; how long is too long? Heavy periods are, at best, inconvenient, and at worst, dangerous to your health. So let’s talk about what’s happening, why it’s happening, when you might need to involve a doctor, and what you can do about it.*

What causes heavy flow periods in perimenopause?

Here’s how it works:

In a period, the level of hormone FSH (follicle stimulating hormone) rises, causing eggs to mature in the ovaries. These follicles produce estrogen, and the estrogen in turn causes the lining of the uterus (the endometrium) to thicken, to prepare to receive a fertilized egg. Ovulation (the release of the mature egg) creates progesterone, and when the progesterone goes away because the egg isn’t fertilized, the endometrium is sloughed off, during what we know as our period.

However, during perimenopause periods, there aren’t as many follicles to stimulate, so the body bumps up the FSH, resulting in more estrogen being created. More estrogen means the uterine lining becomes even thicker – causing heavier bleeding and perimenopause periods lasting longer. This whole process can take longer, too, resulting in the longer gaps between periods. Finally, it’s more common not to ovulate in perimenopause, so in some cycles, the endometrium continues to thicken until it has to be shed – resulting in a very heavy flow.

What does “normal” menstrual flow look like?

Like everything in perimenopause and menopause, “normal” can cover a startlingly wide range of experiences. Some women notice a slight increase in flow or duration of their period; others are unwilling to leave their homes for fear of leaking.

“Normal” menstrual flow – for premenopausal women – is about 2-3 tablespoons over 3-5 days, though even that is just an average, and many women have higher or lower flows for shorter or longer times. Any amount of blood between 25-80 mls is within “normal” range, though that can be hard to measure unless you use a menstrual cup that has measurements on it.

The usual way to measure flow is how often you need to change your protection. During a normal period, you shouldn’t have to change your tampon or pad more than every 4-5 hours. Remember, however, that this can vary from woman to woman, so if your experience is different, that’s probably just fine.

You may see blood clots, especially in the heaviest part of your cycle; as long as the clots are smaller than a quarter, no worries.

What does heavy menstrual flow look like?

Heavy flow is defined as anything over 80ml per period, and it usually means you’re changing your protection every hour or two. As a reference, twelve to sixteen or more soaked sanitary products during a period means you’re experiencing heavy flow. You may also see more or larger clots. In menopause and perimenopause, pink spotting is common during times of heavy flow.

What are the impacts of having heavy periods?

While the occasional heavier period is completely normal during perimenopause, there are health ramifications to be aware of.

  1. Blood volume. If you feel dizzy or your heart pounds or your head swims when you get up from lying or sitting, the amount of blood in your system is too low. Replace it with salty fluids like tomato juice, broths, etc. You’ll need to bump up your fluid intake by as much as 4-6 cups.
  2. Iron deficiency. Anemia is pretty common, especially if you’ve had a few heavy cycles in a row. You can take an iron supplement every day and increase the iron-rich foods in your diet: liver, egg yolks, dark leafy greens, and dried fruits.
  3. Increased stress. Many women would probably say having their period adds a layer of stress to their lives, but concern over leaking or excessive bleeding can really impact a woman’s life.

What else can cause heavy bleeding besides perimenopause?

Though heavier flow and periods lasting longer during perimenopause are relatively normal, there are other causes for menorrhagia– some much more serious than a hormonal imbalance. According to Everyday Health, other reasons for heavy bleeding include uterine fibroids, endometrial polyps, infections, weight changes, stress, bleeding disorders, conditions related to pregnancy, and uterine cancer. Mayo Clinic says heavy bleeding can also result from using an IUD or certain medications like anti-inflammatories, hormones, and anticoagulants. Hypothyroidism may also be responsible for heavy bleeding. There are many menstrual irregularities in menopause, and a wide range of causes.

When do I need to talk to a doctor?*

As always, you know your body best, and you should never hesitate to get professional help if you think you need it. If you experience heavy bleeding, you should probably consult your ob/gyn to rule out other causes. Here are some things to look out for:

  1. Bleeding so heavy it soaks a pad or tampon in an hour and lasts for more than two hours.
  2. Clots larger than a quarter.
  3. Dizziness, breathlessness, fatigue.
  4. How long is too long for periods during perimenopause? Bleeding that lasts more than two weeks should be addressed with a professional.
  5. Bleeding after menopause.
  6. Bleeding after sex.

If any of these sound familiar, make an appointment with your ob/gyn.

What can I do about heavy bleeding?*

If heavy bleeding is impacting your life – even if the cause isn’t dangerous – there are ways to control it. As usual, they run the gamut from lifestyle changes to surgery.

Lifestyle:

  1. Manage your weight. Fat tissue produces estrogen, which, if you remember, thickens the uterine lining, and the thicker lining results in a heavier period.
  2. Take NSAIDs. Nonsteroidal anti-inflammatories like ibuprofen (Advil, Motrin IB) or Aleve can help reduce blood loss.
  3. Check your birth control and other medications. Since these can contribute to heavy bleeding, you might want to check with your doc on finding alternatives.

Medications:

There are medications that can reduce heavy bleeding in perimenopause, including some hormones (birth control pills, progestin-releasing IUDs), and tranexamic acid (a non-hormonal drug).

Surgery:

If other methods don’t work or are otherwise ruled out, there are surgical procedures to reduce or eliminate heavy bleeding:

  1. Hysterectomy. The removal of the uterus obviously ends heavy bleeding. There are health concerns from this procedure as well, so weigh the pros and cons with your doctor and family.
  2. Endometrial ablation. This surgical destruction of the lining of the uterus can slow or stop menstrual flow. While women can still get pregnant after an ablation, it may be more difficult or riskier.
  3. Removal of polyps or fibroids. Both polyps and fibroids can trigger heavy bleeding, so surgical removal may be recommended.

Heavy bleeding is spectacularly annoying, but for most women it doesn’t happen often or long enough for concern. Weird periods are to be expected in our 40s and up.

But if heavy bleeding is disrupting your life to an extraordinary extent, or if you feel you may be experiencing something outside the (admittedly wide) range of “normal,” please see your doctor. Rule out more serious causes, get help and advice to handle what’s happening. Then share with us in the comments or on genneve’s Facebook page or in Midlife & Menopause Solutions, our closed Facebook group.

*As always, the information in this blog is for educational purposes only and is never meant to replace the advice and care of a qualified health care professional. If you think you need help, for crying out loud, go get it.

Got symptoms? Not sure if what you’re experiencing is “normal”? Check out our other “symptom of the month” posts for information on tingling fingers, frozen shoulder, painful breasts, cold flashes, and more.

When Sheryl Gurrentz began hosting “hormonal happy hours” to research her coauthored book A Strange Period: Insights Into the Bizarre Experiences of Perimenopausal Women, she discovered just how wild women’s menstrual periods become during the years leading up to the big change.

“One woman told me she’d had cycles that were 41, 55, then 18 days long — it sounded like a locker combination,” Gurrentz says. “Another was bleeding through a maxi pad plus a tampon. I myself was taking more home pregnancy tests during perimenopause than in my 20s. We assume our periods will taper off and stop, but it doesn’t work that way.”

Nope. Until recently, information about perimenopausal periods was often more fiction than science, even among many health experts. Changes start sooner than was once believed, as early as your late 30s, and can last up to 10 years. Cycles can stretch to 80 days — a longer interval than was once known — or may be shorter than usual. Heavy bleeding and long periods are more common than many women expect — over 30% report very heavy periods. And at least one in four say their periods interfere with their lives, so they may put khaki skirts in storage, shun sex and social events, even call in sick to work.

More than 30% of women report very heavy periods.

The march toward menopause is not a steady one for many. In one study, half the women said their cycles were so variable, they didn’t know what to expect, and no wonder: Estrogen and progesterone can be riding their own crazy roller coasters, and aging ovaries may or may not pop out an egg. The lining of your uterus may stay in place … or it may decide to rush for the exit. Wacky hormones also mean that the other no-fun signs of an impending period — PMS, bloating, tender breasts, fatigue — could come at any time, stick around longer, and feel worse than ever, even if they don’t herald an actual period’s arrival.

But don’t just shrug off all the weirdness: Fibroids, polyps, and underlying health problems like a misbehaving thyroid or even precancers and cancers can set things awry. And there’s plenty your doctor can do to ease symptoms. “It’s important to track your cycle,” says Devorah Wieder, M.D., of the Cleveland Clinic. “And then it’s worth calling your doctor if you notice a change.”

Here’s a rundown of what may be bugging you and why — plus ways to tame symptoms, from the simplest (over-the-counter pills) to the more involved (surgery).

1. “My period won’t stop.”

The average menstrual flow lasts four to six days, but during perimenopause, it can go on — and on. Some months you may not ovulate at all (often the case during these years), and your ovaries may not pump out predictable levels of estrogen and progesterone. This imbalance can cause the uterine lining to become too thick. Then, when you get your period, it can take forever for the lining to shed.

IT COULD ALSO MEAN you have uterine polyps — mushroom-like “skin tags” growing from the walls of your uterus — which can lengthen bleeding.

TELL YOUR DOCTOR IF you’ve had periods that last more than seven days — or several days longer than is normal for you. “If you usually have two-day periods and now you’re bleeding for six or seven days, that may signal there is something different going on,” says Julia Schlam Edelman, M.D., a clinical instructor at Harvard Medical School. “You might have precancerous changes to the lining of your uterus, which won’t show up on your regular Pap test.”

2. “It’s so heavy.”

There’s a reason your drugstore’s feminine-products aisle is jammed with 20 different varieties of super maxi pads: Women commonly experience heavy bleeding during perimenopause. And if you’re overweight, heavy periods are even more likely — 50% more so, in one study, and for extremely overweight women the chances of heavy bleeding doubled.

IT COULD ALSO MEAN you have a fibroid, a noncancerous tumor that starts in the muscle wall of the uterus (or you may have multiple fibroids, as is often the case).

TELL YOUR DOCTOR IF heavy periods interfere with your life or you’re feeling extra tired. You could be anemic as a result of excess blood loss. But simply taking iron may not correct the problem. It is important to learn the cause, since other, more serious conditions — precancers and cancers of the uterine lining — can cause heavy periods as well.

3. “I’m spotting.”

Some women may bleed a little at mid-cycle, when they ovulate, notes Dr. Wieder. And hormone shifts often explain spotting between periods.

IT COULD ALSO MEAN you have a polyp, which may bleed between periods. Or, you could have a condition called adenomyosis, in which lining tissue lodges in the muscle wall of the uterus and blood may leak out between periods. Spotting can also signal an infection or precancerous changes in the lining of your uterus.

TELL YOUR DOCTOR IF you have any spotting. A regular gyno exam can pick up many of these causes, though you may need an endometrial biopsy.

4. “It’s baaa-ack.”

(After five months!) You’re planning a menopause party when, out of the blue, you’re wrestling adhesive-backed pads into your panties again. “This usually means that your brain and your ovaries were actually still having a conversation and, finally, one reluctant egg responded,” explains Tara Allmen, M.D., a gynecologist at New York City’s Center for Menopause, Hormonal Disorders and Women’s Health.

The time between periods does lengthen as your hormones lurch toward menopause — in one study of 120 women, the average cycle length was 80 days in the 12 months before their final period.

IT COULD ALSO MEAN an underactive or overactive thyroid gland.

TELL YOUR DOCTOR IF you do not bleed for 90 consecutive days and then get your period again. Building up several months’ worth of lining in your uterus can put you at risk for precancerous changes called hyperplasia.

Yes, You Can Still Get Pregnant

True, it’s harder when you’re older, but more than 30% of pregnancies in women over 35 are unintended (maybe because many, especially in their 40s, skip birth control?). Consider yourself fertile until you’ve gone 12 consecutive months without a period. Then you are officially out of “peri” and into menopause.

How to Relieve Perimenopause Symptoms

Medications and Contraception

NSAIDS

These can include ibuprofen (Advil), naproxen (Aleve), or a prescription anti-inflammatory like mefenamic acid (Ponstel). They can lighten heavy or long periods for about half of women and also eases cramps for 70% by correcting prostaglandin imbalance. The downside is an increased risk of gastrointestinal bleeding.

Low-Dose Pills, Patch, or Ring

These can address heavy bleeding, long periods, PMS, and breast tenderness by preventing excess build-up of uterine lining. A 21-day pill regimen keeps you on a regular cycle; continuous and extended regimens either stop your periods or let you have one four times a year. They can cut menstrual-blood loss 50%, but breakthrough bleeding can occur.

Intrauterine Device (IUD)

IUDS may also help with heavy bleeding by thinning the lining. They can reduce blood loss up to 86% in three months and up to 97% in 12 months. Hormone-related effects may include irregular bleeding (which usually gets better over time) and breast tenderness.

Surgical Options

D&C and/or Hysteroscopy

In a dilation and curettage, a doctor removes uterine polyps and lining tissue; in a hysteroscopy, a thin, lighted tube is inserted into the uterus and any polyps are snipped out. Polyp removal improves abnormal bleeding 75% to 100%, but polyps may grow back.

Endometrial Ablation

To help with heavy bleeding or long periods, a layer of uterine lining is removed via radiofrequency waves, freezing, or other techniques. This controls bleeding for 60% to 80% of women, but you may need a repeat in a few years; up to 28% of women ultimately opt for a hysterectomy.

Hysterectomy

Removing the uterus means no more periods — or period problems. Research suggests many end up more satisfied with this major surgery than with less aggressive approach. Laparoscopic or vaginal procedures are less invasive and require shorter recovery.

Blood Clots as a Symptom of Menopause?

Q1. Is it common to have thick clumps, or clot-like blood, when nearing menopause? This has been happening more frequently during my menstrual period and I never experienced this issue before. If not, what else could blood clots in my menstrual blood mean?

— Melissa, Nebraska

For many women, the pattern of their menstrual cycle and the consistency of their menstrual flow will indeed change as they get closer to menopause. The interval between your menstrual periods may also fluctuate as you near the menopausal stage. But if you are noticing lots of blood clots in your menstrual blood and are experiencing unusually heavy bleeding, then you should discuss it with your doctor as the problem could be related to something other than menopause. I would also recommend that you be checked for anemia, a condition associated with a deficiency in your red blood cell count that can make you feel weak and tired. If the total amount of your menstrual blood flow is much greater than your usual periods in the past, then that can lead to anemia and will require evaluation and treatment. Generally speaking, any time you notice a new pattern in your menstrual cycle or see peculiarities in its flow, such as the blood clots you mentioned, it’s best to be examined by your doctor so that he or she can determine the cause. The blood clots you’ve been experiencing could in fact be related to your approach toward menopause, but it’s a smart idea to rule out any other possibilities first.

Q2. I have large blood clots in my period. Is this a sign of perimenopause?

Blood clots can be a sign of a variety of things and sometimes they are just a normal part of menstruation. The most common first sign of perimenopause is having your periods come a little closer together. Then they can become irregular and change in character as you stop ovulating every month and your hormones get more erratic. And every woman does this a little differently.

Heavier, clotty periods can also be a sign of gynecologic problems that occur frequently in midlife women. These include uterine fibroids (common muscular tumors in the uterus) and endometrial polyps (benign growths of the uterine lining).

There are some other patterns you should tell your clinician about if they happen to you, including periods closer than every 20 to 21 days (from the beginning of one to the beginning of the next), periods that last three or four days more than usual, bleeding between periods, bleeding after sexual intercourse or periods that are much heavier than you are accustomed to.

Learn more in the Everyday Health Menopause Center.

The term “menopause” can be daunting on its own, but couple it with the words “abnormal bleeding,” and you may find the hair on the back of your neck standing up. Menopause is a normal, physiological event which can occur naturally or be induced through medical interventions, such as surgery, pelvic radiation therapy, chemotherapy or systemic illness. Women are considered in menopause if they have not had a menstrual cycle for at least a year. With life expectancy of women increasing to up to age 80, women may spend more than one-third of their life beyond menopause.

RETURN OF BLEEDING — IS THIS NORMAL?

During menopausal years, women may experience a return of vaginal bleeding. They may spot for a day or a week, and then bleeding may go away. When bleeding does stop, it’s natural not to think about it again. Although bleeding may have been caused by some form of physical activity, vaginal discharge, yeast infection or vaginal itching, there may be a chance that it actually was a symptom of something more serious, such as hyperplasia, which is an increase in abnormal cells, or cancer.

As women age, they are at greater risk for hyperplasia and cancer of the uterus. In fact, the increase is nearly 75 percent greater for women who are between the ages of 70 and 74. Other causes of bleeding can be related to thinning of the lining of the uterus, otherwise known as atrophic lining of the uterus, polyps, fibroids, thyroid abnormalities or coagulation defects.

SEEKING MEDICAL ATTENTION

Women who have experienced a return of bleeding after menopause should consult with a women’s health provider immediately. The provider may do a biopsy of the lining of the uterus or conduct an ultrasound to look at the thickness of the lining of the uterus. A biopsy is a procedure that entails removing a small amount of tissue from the uterus that will be sent on to viewed by the pathology lab. A biopsy can be done in the clinic and most often is tolerable; however, there are times when it can be painful or when the provider is not able to get a sample because the cervix is closed and cannot be dilated.

During the ultrasound, if the lining appears to be more than 4 mm, the provider will want to proceed with a biopsy. It is not always necessary to have an ultrasound done before having a biopsy.

If a biopsy is not an option for you or if bleeding continues despite a normal biopsy, the provider may suggest a hysteroscopy. During this surgical procedure, the inside of the uterus can be visualized with the help of a scope. The advantage of this approach is that the biopsy can be taken under direct visualization, and if any there any polyps or fibroids present, they can be treated and removed.

Simply put, women who experience post-menopausal bleeding should seek medical attention immediately. Early detection of abnormal cells or cancer increases the survival rate.

Madhu Bagaria, M.D., is an OB-GYN in Austin, Minnesota.

Bleeding after menopause

Menopause is the time after you have your last period. Because your final periods can be irregular, menopause is confirmed 12 months after your last period. Bleeding or spotting after this point is called postmenopausal bleeding (PMB).

Postmenopausal bleeding needs to be checked out by a doctor. Mostly the cause will be something very simple and treatable but occasionally it is a sign of more serious disease.

It is not normal to bleed or spot 12 months or more after your last period.

Bleeding after menopause is usually a sign of a minor health problem but can sometimes be an early sign of more serious disease.

When detected early, most conditions causing bleeding after menopause (including cancer) can be successfully treated.

What causes bleeding after menopause?

Bleeding after menopause is rarely cause for concern. It does need to be investigated, however, because in very few cases it will be an indicator of something more serious.

In about 90 per cent of cases, a particular cause for bleeding after menopause will not be found. This is not a cause for alarm, if there is a serious problem it will be identified through investigations. Most of the time, postmenopausal bleeding is caused by:

  • inflammation and thinning of the lining of your vagina (called atrophic vaginitis)
  • thinning of the lining of your uterus
  • growths in the cervix or uterus (called polyps) which are usually not cancerous
  • thickened endometrium (called endometrial hyperplasia) often because of hormone replacement therapy (HRT)
  • abnormalities in the cervix or uterus.

These are generally not serious problems and can be cured relatively easily.

However, about 10 per cent of the time, post-menopausal bleeding is linked to cancer of the cervix or uterus and so it is very important to have it investigated.

Treating post menopause bleeding

If you have postmenopausal bleeding it is important to have it investigated.

You will most likely be referred to a gynaecologist who may:

  • ask you questions about the history of your health
  • examine you
  • do a blood test
  • look at the inside of your vagina and cervix using special tongs (called a speculum). At the same time, they may take a tiny sample of your cervix for testing (called a cervical screening test).

The kind of treatment you have will depend on what is causing the bleeding.

  • Atrophic vaginitis and thinning of the endometrium are usually treated with drugs that work like the hormone oestrogen. These can come as a tablet, vaginal gel or creams, skin patches, or a soft flexible ring which is put inside your vagina and slowly releases the medication.
  • Polyps are usually removed with surgery. Depending on their size and location, they may be removed in a day clinic using a local anaesthetic or you may need to go to hospital to have a general anaesthetic.
  • Thickening of the endometrium is usually treated with medications that work like the hormone progesterone and/or surgery to remove the thickening.

Before treatment there are a number of tests and investigations your gynaecologist may recommend.

  • An ultrasound of your pelvis to get a picture of your cervix, uterus, endometrium and ovaries. An external ultrasound is a small hand held device (called a transducer) that the doctor will move over you belly. An internal ultrasound is a small wand that the doctor inserts into your vagina to get a better image of your cervix and uterus.
  • A pipelle test to take and test a sample or biopsy of your endometrium. This can be done without anaesthetic in a day clinic with a thin tube (or pipelle) which is put into your uterus (through your vagina) and gently sucks up a small sample of cells.
  • A hysteroscopy to take photos of your cervix, uterus and endometrium. A sample or biopsy of your endometrium may also be taken for testing. A hysteroscopy involves putting a long, narrow instrument (called a hysteroscope) into your uterus through your vagina. It can be done under local or general anaesthetic.
  • A dilation and curette (D&C) to scrape away part of your endometrium and test it. This is done under a general anaesthetic.

All treatments should be discussed with you so that you know why a particular treatment or test is being done over another.

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