Postmenopausal Bleeding: Causes, Symptoms & When to Worry

Postmenopausal bleeding (PMB) is defined as vaginal bleeding occurring after 12 months of amenorrhea due to menopause. It is considered abnormal and warrants investigation.

 Etiology (Causes) of Postmenopausal Bleeding

1.    Benign Causes

o   Senile Endometritis (Atrophic endometrial changes)

o   Endometrial or Cervical Polyps

o   Cervical Erosion

o   Decubitus Ulcers (Pressure Ulcers) in Prolapsed Uterus

2.    Malignant Causes

o   Endometrial Carcinoma (Most common cause of PMB)

o   Cervical Cancer

o   Vaginal Malignancies

3.    Hormonal & Dysfunctional Causes

o   Hormone Replacement Therapy (HRT)-Induced Bleeding

o   Dysfunctional Uterine Bleeding (DUB) Post-Menopause

4.    Infectious Causes

o   Tubercular Endometritis

o   Senile Vaginitis

5.    Other Causes

o   Foreign Body in Vagina

o   Urethral Caruncle

 Clinical Features

• Painless vaginal bleeding after menopause
• Scanty or heavy bleeding
• Intermittent or continuous spotting
• Foul-smelling discharge (suggestive of malignancy)

 Investigations for Postmenopausal Bleeding

1.    Clinical Examination

o   General systemic examination

o   Per abdominal and pelvic examination

2.    Speculum Examination

o   Visualizes cervix and vagina

o   Detects erosions, ulcers, polyps

3.    Bimanual Examination

o   Assess uterine size and mobility

4.    Ultrasound (USG)

o   Transvaginal Ultrasound (TVUS) to check endometrial thickness

o   Endometrial thickness >4 mm → Suspicious for pathology

5.    Endometrial Sampling & Biopsy

o   Gold standard for diagnosing malignancy

6.    Hysteroscopy

o   Direct visualization of endometrial cavity and biopsy

7.    Pap Smear & Cervical Biopsy

o   Rule out cervical cancer

8.    Blood Investigations

o   Complete Blood Count (CBC)

o   Hormonal assays (if on HRT)

 Management & Treatment

1. Observation & Follow-Up

• For benign, self-limiting cases
• Regular monitoring with ultrasound

2. Medical Management

• Hormone Therapy (For Atrophic Endometritis)
• Antibiotics (For Infections)
• Iron Supplements (For Anemia Due to Bleeding)

3. Surgical Management

• Hysteroscopic Polypectomy (For Polyps)
• Dilatation & Curettage (D&C) – Diagnostic & Therapeutic
• Hysterectomy (For Confirmed Endometrial or Cervical Cancer)
• Laparotomy (For Advanced Malignancies)

 Key Points

• Postmenopausal bleeding should always be investigated
• Endometrial thickness >4 mm on TVUS requires further evaluation
• Endometrial biopsy is the gold standard for diagnosis
• Early detection of malignancy improves prognosis

Keynote Symptoms of Postmenopausal Bleeding (PMB)

1.    Abnormal vaginal bleeding occurring after 12 months of menopause

2.    Intermittent or continuous spotting, often painless

3.    Heavy bleeding with weakness and fatigue

4.    Foul-smelling discharge (if infection or malignancy is present)

5.    Pelvic pain or pressure symptoms in advanced cases

 1. Lachesis

Indications:

• Heavy, dark, offensive bleeding after menopause
• Hot flashes, intense heat sensation, and intolerance to tight clothing

Keynote Symptoms:

• Symptoms worsen after sleep.
• Profuse, dark bleeding with clot formation.
• Left-sided complaints dominate.
• Sensation of suffocation, worse in warm rooms.
• Talkative, suspicious personality.

 2. Sepia

Indications:

• Scanty or excessive postmenopausal bleeding with vaginal dryness
• Feeling of pelvic congestion and heaviness

Keynote Symptoms:

• Bearing-down sensation in the lower abdomen.
• Aversion to sex and dryness of the vagina.
• Indifference to family and emotional detachment.
• Worse in cold air and better with exercise.
• Brownish pigmentation on the face.

 3. Phosphorus

Indications:

• Painless, bright red bleeding that lasts for an extended period
• Postmenopausal bleeding with general weakness and dizziness

Keynote Symptoms:

• Strong craving for cold drinks.
• Weakness and exhaustion after bleeding.
• Bleeding from multiple sites (gums, nose, uterus).
• Sensitive, emotional, and fearful nature.
• Worse from lying on the left side.

 4. Trillium Pendulum

Indications:

• Heavy, gushing bleeding that stops and starts again
• Severe weakness, dizziness, and fainting spells due to blood loss

Keynote Symptoms:

• Feels as if the hips and back would fall apart.
• Bright red bleeding with fainting.
• Better when lying down and pressing the abdomen.
• Worse from movement and exertion.
• Severe anemia with cold extremities.

 5. Millefolium

Indications:

• Painless, passive bleeding after menopause
• Hemorrhage due to fibroids or endometrial thickening

Keynote Symptoms:

• Profuse, bright red bleeding with no clotting.
• Worse from exertion or standing too long.
• Bleeding episodes occur frequently.
• No pain or cramping with the bleeding.
• Better in open, fresh air.

 Additional Management for Postmenopausal Bleeding

• Investigations (Ultrasound, Pap Smear, Endometrial Biopsy) to rule out malignancy
• Iron supplements if anemia is present
• Regular gynecological follow-ups