Vaginal Bleeding

Many older women experience unexpected vaginal bleeding months or even years after their last regular period. Any vaginal bleeding that occurs after the onset of menopause is considered abnormal, even though it is relatively common. Such bleeding can signify pre-cancer or cancer, including cancer of the uterus or vagina, and so should never be ignored. But bleeding has many other causes. A postmenopausal woman may experience vaginal bleeding because the low estrogen levels after menopause make the vaginal tissue thin and fragile. Thickening of the uterine lining usually is caused by estrogen replacement therapy. Other noncancerous causes of vaginal bleeding include growths protruding from the cervical or uterine lining (cervical or uterine polyps), growths in the uterine wall (fibroids), and infections.

Symptoms

Often, vaginal bleeding occurs without any other symptoms. Symptoms that may accompany vaginal bleeding include abdominal or pelvic cramping or discomfort. Such symptoms cannot generally help distinguish cancer from other causes of vaginal bleeding.

Diagnosis

Vaginal bleeding is usually obvious, but its causes may not be. In making a diagnosis, a doctor first performs a physical examination of the vulva, vagina, uterus, and ovaries (a pelvic examination). A Papanicolaou (Pap) test, in which cells from the surface of the cervix are collected, is then performed to identify vaginal or cervical cancer. A biopsy is performed if an abnormal growth is found during the pelvic examination.

If the physical examination and Pap test do not reveal a cause, a biopsy of the uterine lining (endometrial biopsy) is usually performed to rule out cancer of the uterus. This type of biopsy can be done quickly and safely without anesthesia in a doctor's office. Alternatively, an ultrasound of the uterus can be performed to measure the thickness of the lining. If the lining is thickened, fluid can be infused into the uterus during the ultrasound to identify any polyps or fibroids. If none are identified, a biopsy is then performed.

Another way to identify polyps, fibroids, or cancerous tissue is by hysteroscopy, in which a flexible viewing tube is inserted through the vagina and cervix and into the uterus. Hysteroscopy can be performed in the doctor's office or operating room.

Blood tests to assess the blood count may also be useful if bleeding is heavy or has occurred for a long time.

Treatment

Treatment of vaginal bleeding depends on the cause. Bleeding due to estrogen deficiency is treated with estrogen supplements. If a woman taking estrogen or progesterone develops bleeding, the dosage of either can be altered. For example, estrogen can be given in a lower dose. Occasionally, dilatation and curettage (D and C) is necessary if bleeding does not respond to dosage changes. Hysteroscopy can be used to remove abnormal tissues. Alternatively, laser, electricity, or heat can be used through the tip of the hysteroscope to destroy the lining of the uterus. Polyps and fibroids can also be removed surgically. A woman whose fibroids are growing larger may need to have them or the entire uterus surgically removed to ensure against the possibility of cancer. Another possible treatment, once it is determined that cancer or other abnormal growths are not the cause of bleeding, is insertion of a progesterone-containing intrauterine device (IUD). A suspected infection of the uterus can be treated with antibiotics. Endometrial and cervical cancer can be treated with a combination of surgery, radiation, and drugs.