Month after month, year after year, we are running for the bathroom searching for the tampon or pad that we keep buried in our purse for an emergency. After realizing that we used the emergency supply last month and never restocked, we seek out help from one of our bathroom mates who smiles and says, “Don’t worry; I’ve been there.” The truth is, we all have at some point; the monthly mess is just a part of a woman’s life. It can be so unpleasant—the cramps, the moods, the pimples, and of course, the endless bleeding—that it’s hard to imagine ever missing this. I mean, if your 20-year-old self could talk to your 50-year-old self, what a conversation that would be! When you are in the thick of those reproductive years, a little irregular bleeding here or there often goes unnoticed: what’s a little more bleeding? You probably don’t make much of it and maybe even forget to mention it to your doctor. It is, so to speak, just a drop in that much larger bucket. However, when bleeding arises post-menopause, it can be serious and should never be shrugged off, ignored, or go unnoticed.
Menopause is the end of a very, very, very long race; “miles” of menses ultimately come to an end. While this race is long, its end is gradual and is preceded by a major “spacing” out of rest stops. All regularity and predictability are lost, and irregularity and the unknown take the lead. Medically, this time of irregular periods is known as perimenopause; perimenopause and the haphazardness that it brings (both physical and often emotionally) can (oh joy) last for years.
It isn’t until a full year from the last period that you receive your official medal (a.k.a. menopause). From this point on, the flood gates are closed. No more bleeding should occur. Without the ebbs and flows of estrogen and progesterone made by the ovaries, the stimulus for a uterine lining to be produced and shed monthly is lost. The uterine lining becomes thin (no diet required!) and in most instances remains that way indefinitely. If it starts to receive mixed messages (um, no way, that’s not what she told me!), it can thicken and bleed. But let’s cut the game of telephone ASAP. This is not evidence that you are once again fertile. It can hint at a seriously serious situation, such as endometrial cancer, which requires immediate attention. Endometrial cancer is the most commonly diagnosed gynecologic cancer; about 55,000 women will be diagnosed in the US each year. Luckily, most endometrial cancers give you a heads up: a “get out of the way; the bus is about to hit you”-type of thing. For most women, bleeding, long after the days when there was bleeding, will happen.
Bleeding is an obvious and often early sign that something is off. Because it is so visible, endometrial (uterine) abnormalities are often picked up early in the game. In fact, in many cases, they are not even fully cancerous but rather precancerous (about 70% of endometrial cancers are stage I when diagnosed). The precancerous condition is called endometrial hyperplasia. Basically, the cells are becoming a little hyperactive and if untreated could be on their way to some serious Ritalin-requiring behavior. There are four types of endometrial hyperplasia, with some being more in line with cancer and others just slightly out of line with normal. As a common precursor to endometrial cancer, endometrial hyperplasia in a post-menopausal woman often leads to a hysterectomy.
Not all postmenopausal bleeding is bad. Some is just a reflection of a thin uterine lining or thin vaginal wall (medically termed atrophic). Think of dry hands or lips in the winter…they get dry, chapped, and cracked. This can lead to bleeding. There is no medical problem that caused the bleeding (it’s your lack of lotion and chapstick!). And while it can be unsightly, it usually doesn’t require medical treatment. The same goes for what we call endometrial atrophy. With years of low estrogen, things can sort of thin and shrivel. One such thing is your uterine lining. It can become so thin that it bleeds. Last, in certain cases the answer is C: neither of the above. Often, a benign structure like an endometrial polyp (an overgrowth of glandular tissue) can cause postmenopausal bleeding.
Our job is to sort out which type of bleeding you are having—the “I need some chapstick bleeding” or the “I need some surgery bleeding.” We don’t have eyes in the back of our head (even though our kids think we do), and we can’t diagnose endometrial pathology just by looking at your abdomen. In order to make a diagnosis, be it a cancer, hyperplasia, a polyp, or just a really thin lining, we need to perform an ultrasound and possibly even an in-office biopsy.
Sometimes, if more information is needed to make the appropriate diagnosis a D&C is required. The thickness of the uterine lining on ultrasound serves as sort of the gatekeeper for what should be done next. In this case, the line in the sand is 4mm. When the lining is less than or equal to 4mm, you pretty much have the all clear. No further testing is required unless the bleeding continues to occur because the risk of uterine cancer is so low. When the uterine lining is greater than 4mm, you have entered the no-fly zone, and further evaluation is required.
Luckily, the warning signs are fairly bright, so most endometrial cancers are diagnosed and treated early (making survival rates quite high). While most women with endometrial hyperplasia and cancer will require a surgical procedure (hysterectomy), it is a small price to pay to be cancer free. While seeing red again can be alarming, it is not always bad. However, you do need to sound the sirens (a.k.a. call your OB/GYN) and police the situation. Even the smallest drops in the bucket matter. When you are postmenopausal, every spot matters.