Post-menopausal bleeding refers to any vaginal bleeding that occurs after menopause. You are considered menopausal if you are over 40, have not had a period for over 12 months, and are not pregnant or breastfeeding.

This definition excludes women whose periods have stopped due to other causes such as eating disorders, PCOS, or certain medications. While PMB is often caused by benign conditions, it is important to investigate as up to 10% of cases may indicate precancer or cancer.

Common Causes of PMB

1. Atrophic vaginitis (thinning out of vaginal skin): This is the most common cause of PMB (70%). This condition usually occurs secondary to the fall in the hormone oestrogen that occurs at menopause and results in the tissues of the vagina becoming thin and fragile. This makes them more prone to inflammation and bleeding. If you have this condition you may also experience vaginal dryness, recurrent urinary infections and discomfort during intercourse.
2. Endometrial polyps or fibroids: Polyps are localised overgrowth of the cells which line the womb, usually into finger-like projections. They are found in 15-20% of ladies with PMB. These polyps are benign in more than 90% of cases.
3. Endometrial hyperplasia (pre-cancer) or cancer: This is diagnosed in up to 10% of ladies referred with PMB. There are 2 types of endometrial hyperplasia (pre-cancer): (i) Non-atypical: with 1-3% risk of progression into cancer if left untreated, and (ii)Atypical: with up to 40% risk of progression into cancer if left untreated.
4. Other causes: Taking Hormone replacement therapy (HRT) or having cancer of the ovary, vagina or vulva.

What to Expect at the Clinic

You will first of all be seen by one of the doctors or nurses who will ask you a few questions about the bleeding and about your general health. This usually only takes a few minutes.

We then proceed to an examination with your consent. This will involve both an ultrasound scan and a pelvic examination.
The ultrasound will be a trans-vaginal (‘internal’) ultrasound scan in order to examine the thickness of the womb lining, check the appearance of the womb and look at the ovaries.

The scan involves gently inserting a thin ultrasound probe with a rounded tip into the vagina in order to get a good look at the womb and the ovaries. If the lining of the womb appears thicker than expected (it is normally very thin after the menopause), the doctor or nurse may suggest trying to obtain a sample of the womb lining (this is called a Pipelle biopsy).

All women will be offered a pelvic examination which is like a smear test. Only about a quarter (25%) of women at the clinic will be asked to consider having a biopsy. In the others, the scan alone provides enough information.

The biopsy involves passing a very thin straw-like piece of plastic (the Pipelle) through the cervix (the neck of the womb) during the pelvic examination and into the womb, then using gentle suction to gather some of the cells from the womb lining. Some women do not find this sore, but others will experience some cramping pain which quickly resolves once the procedure is completed.

It is important to stress that at any point during this procedure — or during the other examinations — you should feel free to ask the doctor or nurse to stop or to pause if you wish to.

The biopsy can tell us if there are any cancerous or precancerous cells inside the womb. You can expect some light spotting or bleeding after this test so you may wish to wear a pantyliner or sanitary pad for the rest of the day.

Next Steps

It may be the case that, by this point, we have enough information to decide what has caused the bleeding. If so, we will explain this to you and we may recommend some treatment. If a Pipelle biopsy has been obtained, this will be sent away to the laboratory in order to be analysed. Once this has been done, the doctor will contact you by letter with the result and will let you know whether any further investigations or treatment is recommended..This normally takes three to four weeks. If you have not heard from us by four weeks, please contact the secretary of the Consultant whose clinic you attended.

If we are unableto take a Pipelle biopsy, we may recommend that you come back for a procedure performed under anaesthetic called a hysteroscopy. This is a test that allows the doctor to look inside the womb using a small telescope, and would be fully discussed with you in the clinic.

The treatment offered will depend on the cause of the bleeding and the doctor or nurse will explain this to you in full.