Postmenopausal bleeding is bloody discharge from the genital tract of varying intensity, occurring against the background of the extinction of menstrual function or after its termination. Menopausal bleeding varies in duration, frequency, volume of blood loss, the nature of discharge (with or without clots). They may have a dysfunctional and organic genesis. In order to determine the causes of postmenopausal bleeding, along with a gynecological examination and ultrasound, it is mandatory to perform an SCD under hysteroscopic control with a histological analysis of the scraping. The tactics of treatment of menopausal bleeding (conservative or surgical) is determined by its cause.
Postmenopausal bleeding is the spontaneous release of blood from the genitals in women during premenopause, menopause or postmenopause. This pathological condition is the most common cause of hospitalization of patients aged 45-55 years in the department of gynecology. The causes of bleeding and treatment tactics largely depend on the period of menopause. According to researchers, postmenopausal bleeding in 25% of cases is combined with uterine fibroids, in 20% of cases – with endometriosis, in 10% of cases – with endometrial polyps. Regardless of the intensity of bloody discharge, duration and volume of blood loss, menopausal bleeding requires mandatory medical control, since it can occur not only against the background of dishormonal disorders and benign changes in the uterus, but also due to malignant tumors.
Depending on the period of menopause in which uterine bleeding has developed, premenopausal, menopausal and postmenopausal bleeding are distinguished. Based on signs such as the volume of bloody discharge, duration, regularity, etc., menopausal bleeding may have features:
- Menorrhagia – heavy cyclic bleeding of the premenopausal period
- Metrorrhagia – bleeding that is acyclic in nature
- Menometrorrhagia – heavy menstruation combined with acyclic uterine bleeding
- Polymenorrhea – uterine bleeding that occurs at regular short intervals (less than 21 days).
In the premenopausal period (4-8 years before menopause), bleeding usually occurs according to the type of menometrorrhagia, and in menopause and postmenopause, when menstruation stops, they have the character of metrorrhagia. Taking into account the causes that caused them, postmenopausal bleeding is divided into dysfunctional, iatrogenic, associated with pathology of the reproductive organs or extragenital pathology.
In the premenopausal period, uterine bleeding is more often dysfunctional and is a consequence of involutional disorders of hypothalamic-pituitary-ovarian regulation. Violation of the cyclical secretion of gonadotropins entails a violation of follicle maturation, yellow body inferiority and luteal insufficiency. In conditions of relative hyperestrogenism and absolute progesterone deficiency, the proliferation phase is lengthened, and the secretion phase is reduced. Uterine bleeding in this period of menopause, as a rule, occurs against the background of endometrial hyperplasia (glandular cystic, adenomatous, atypical or endometrial polyps). This is facilitated not only by age-related decline in ovarian function, but also by metabolic and endocrine disorders (obesity) and immunosuppression.
In addition to ovarian dysfunction, the causes of postmenopausal bleeding can be organic genital pathology: atrophic vaginitis, adenomyosis, uterine fibromyoma, endometrial cancer, cervical cancer, hormone-active ovarian tumors. Often these diseases are combined with hyperplastic transformation of the endometrium, and the pathogenesis of postmenopausal bleeding is mixed. In the anamnesis of women suffering from recurrent menopausal bleeding, there are often indications of abortions, gynecological diseases, operations on the uterus and appendages.
In some cases, postmenopausal bleeding may be caused by taking hormonal drugs as part of replacement therapy. Also, the discharge of blood from the genital tract may be associated with extragenital diseases: hypothyroidism, cirrhosis of the liver, coagulopathy, etc. Since, despite the decrease in fertility, the probability of pregnancy in premenopause remains, with bleeding, conditions such as the threat of miscarriage and ectopic pregnancy should be excluded.
Fluctuations in the duration of the menstrual cycle and changes in the nature of menstruation are noted already at the beginning of the menopausal period – in premenopause. At this time, menstruation may become irregular, be absent for 2-3 months, then resume again. The intensity of menstrual discharge also changes – monthly periods become scarce or, on the contrary, abundant. These phenomena, if they do not have an organic basis, are considered normal “companions” of premenopause.
The reason for an early visit to the gynecologist should be excessively abundant menstruation, with signs of bleeding (if the sanitary pad has to be changed every hour or more often), as well as menstrual discharge with blood clots. Bleeding that resumes during the intermenstrual period or occurs after sexual intercourse cannot be the norm. A woman’s concern should be caused by too long menstruation, the absence of menstruation for 3 months or more, or the resumption of menstruation more often than after 21 days.
The general condition of a woman suffering from postmenopausal bleeding is determined by the degree of anemia, the presence of concomitant diseases (hypertension, pathology of the liver and thyroid gland, oncological diseases).
Since postmenopausal bleeding can signal a wide range of pathological conditions, the diagnostic search includes a whole range of studies. The first stage of diagnosis takes place in the office of a gynecologist (gynecologist-endocrinologist), preferably specializing in menopause problems. During the conversation, complaints are clarified, menograms are analyzed. During a gynecological examination, the doctor may appreciate the intensity and nature of spotting, and sometimes the source of bleeding. In the absence of bleeding at the time of examination, a smear is taken for oncocytology.
At the next diagnostic stage, it is mandatory to conduct a transvaginal ultrasound of the pelvic organs, which allows you to give a conclusion about the presence or absence of pregnancy, pathology of the uterus and ovaries. The complex of laboratory studies may include clinical and biochemical blood tests, coagulogram, determination of the level of beta-hCG, sex hormones and gonadotropins, examination of the thyroid panel, blood lipid spectrum, liver samples.
The most valuable method for determining the source and cause of bleeding is a separate diagnostic curettage performed under the control of hysteroscopy. Histological analysis of endometrial scraping allows differential diagnosis of dysfunctional postmenopausal bleeding and bleeding caused by organic pathology, including blastomatous processes. Auxiliary methods of instrumental diagnostics include hysterosalpingography, pelvic MRI, which allow detecting submucous and intramural fibroids, uterine polyps.
SCD of the mucous membrane of the cervical canal and the uterine body is both a diagnostic and therapeutic measure, because it performs the functions of surgical hemostasis. After removal of a hyperplastic endometrium or a bleeding polyp, the bleeding stops. Further tactics depend on the pathomorphological study. Surgical treatment in the volume of a pangisterectomy is indicated for the detection of uterine adenocarcinoma, atypical endometrial hyperplasia. With large or multiple uterine fibroids, nodular adenomyosis, a combination of fibromyoma and adenomyosis, surgical removal of the uterus is recommended: hysterectomy or supravaginal amputation of the uterus.
In other cases, with benign dishormonal processes that caused postmenopausal bleeding, a set of conservative measures is being developed. To prevent relapses of menopausal bleeding, gestagens are prescribed that contribute to atrophic changes in the glandular epithelium and endometrial stroma. In addition, therapy with progestogens mitigates other manifestations of menopause. In recent decades, antiestrogenic drugs (danazol, gestrinone) have been used to treat postmenopausal bleeding. In addition to the effect on the endometrium, antiestrogens help to reduce the size of uterine fibroids, reduce the manifestations of mastopathy. The use of androgens to suppress menstrual function is possible in women over 50 years of age. Common contraindications for drugs of all groups are a history of thromboembolism, varicose veins, chronic cholecystitis and hepatitis with frequent exacerbations, arterial hypertension.
The use of hemostatic and antianemic drugs during postmenopausal bleeding is auxiliary. If endocrine and metabolic disorders (obesity, hypothyroidism, hyperglycemia, hypertension) are detected, their drug and dietary correction is carried out under the supervision of an endocrinologist, diabetologist, cardiologist.
Relapses of postmenopausal bleeding on the background or after treatment usually indicate undiagnosed organic diseases (submucous myomatous nodes, polyps, endometriosis, ovarian tumors). Menopausal bleeding should always cause oncological alertness, since 5-10% of patients at this age have endometrial cancer as the cause of spotting. Women who have crossed the threshold of menopause should monitor their health no less carefully than at reproductive age, and in case of abnormal bleeding, immediately contact specialists.