Is Spotting After Menopause Normal?

Menopause is defined as twelve consecutive months without menstrual periods, normally at age 49-51. Then the ovaries stop releasing eggs and hormone levels plummet. By definition, no further bleeding can occur. Due to this, any spotting or bleeding from the vagina following menopause is indicative of something being wrong and must be evaluated by a doctor immediately.

The most common individual cause of bleeding after menopause is vaginal and uterine atrophy due to waning estrogens. When the uterine and vaginal lining are thin and dry after being thinned out, the vagina and uterus are susceptible to irritation and bleeding. It is harmless and can be cured, but it is certainly not the only reason for spotting. Infections, polyps, fibroids, or the drug effects of such things as hormone replacement therapy and tamoxifen are also common offenders. But why postmenopausal bleeding is especially concerning is the risk of cancer. Studies have shown that a mere 10 per cent of women presenting with postmenopausal bleeding actually harbour endometrial or cervical cancer, and in fact, more than ninety per cent of endometrial cancer patients present with vaginal bleeding. Due to this single reason alone, any bleeding occurring after the menopause must never be ignored.

Excluding these medical causes, lifestyle is implicated as well. Smoking, heavy alcohol use, obesity, and uncontrolled diabetes can stimulate inflammation, thin the uterine endometrium, and cause bleeding tendency. Importantly, these lifestyle precipitants are reversible. Smoking cessation, better control of diabetes, restriction of alcohol intake and healthful weight maintenance not only reduce the risk for abnormal uterine bleeding but also overall health and well-being in the postmenopausal age group.

Despite these facts, spotting postmenopausal symptoms is commonly neglected. Most women think that a tiny trickle of blood can't do any harm or attribute it to irritation. Some dismiss it as a side effect of hormone replacement, while others are too embarrassed to go to a gynaecologist for bleeding that seems inconsequential. In a few cases, fear of investigation or diagnosis deters women from receiving care in a timely fashion. Such delays, nonetheless, can allow a more advanced condition, like cancer, to progress uncontrolled.

If the woman has postmenopausal bleeding, the initial medical workup is straightforward. The posterior culdocentesis, after ultrasound-measured uterine lining thickness, is preceded by a history and pelvic exam. Additionally, if the lining is abnormal, then an endometrial biopsy would be performed to exclude malignancy. They are quick, non-invasive, and informative. Even a single episode of spotting should be followed, as the sooner the spotting can be detected, the better the treatment and reassurance will be.

It is good to remember that while most causes of postmenopausal spotting are not of a serious nature, the symptom in itself must never be overlooked. Education and awareness are the solutions. By understanding that even small postmenopause bleeding is an alert sign, women can take matters into their own hands and seek assistance early. Shattering the myth that it is always trivial and overcoming the resistance to see a doctor can be a matter of life and death.

Finally, postmenopausal spotting is abnormal and should always be explored. The majority of causes are reversible, like lifestyle-related causes, and most benign conditions are readily treatable once discovered. Alternatively, the minority of these cases can reveal more serious diseases, such as endometrial cancer, and this is where early detection has its pay-off. As a physician, my simple message is: do not ignore spotting after menopause. Acting quickly provides reassurance but also safeguards long-term health and quality of life.

Dr. Esha R Shanbhag

Associate Consultant - Gyneacological Oncology, Aster Whitefield