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ULY CLINIC

20 Septemba 2025, 01:30:45

Postmenopausal vaginal bleeding

Postmenopausal vaginal bleeding (PMB) is defined as vaginal bleeding occurring 6 or more months after menopause. It is an important clinical sign, often warranting evaluation to rule out gynecologic malignancy, but may also result from benign causes such as atrophic changes, infection, polyps, hormonal stimulation, or local pelvic disorders.

Clinical Presentation:

Bleeding may be slight spotting (brown or red) or bright red hemorrhage.
Often occurs spontaneously or following coitus, douching, or straining.
Some patients, especially those with a history of heavy menstrual flow, may minimize the bleeding, delaying diagnosis.
Bleeding may originate from the vagina, cervix, endometrium, fallopian tubes, or ovaries.

History and Physical Examination

History

Determine age and age at menopause.
Identify onset, duration, and pattern of bleeding.
Obtain thorough obstetric and gynecologic history: menarche, cycle regularity, sexual history, parity, fertility issues.
Assess family history of gynecologic cancers.
Note associated symptoms: pelvic pain, urinary changes, systemic symptoms.
Record hormone therapy usage, including estrogen replacement.

Physical Examination

Inspect external genitalia, noting discharge, vaginal mucosa, labia, and clitoris.
Palpate breasts and regional lymph nodes.
Conduct pelvic and rectal examinations to identify masses or lesions.
Assess for systemic signs, such as anemia, cachexia, or abdominal masses.

Medical causes

Cause	Key Features	Associated Findings	Pathophysiology	Management
Atrophic vaginitis	Spotting after coitus/douching; watery white discharge	Pruritus, dyspareunia, burning, pale vagina with decreased rugae, clitoral and labial atrophy	Estrogen deficiency → thinning of vaginal mucosa and friability	Topical estrogen, lubricants, vaginal moisturizers
Cervical cancer	Postcoital or spontaneous spotting; foul-smelling discharge	Pink-tinged discharge, postcoital pain, back/sciatic pain, leg swelling, weight loss, hematuria	Malignant transformation of cervical epithelium	Colposcopy, biopsy, surgery, chemo/radiation
Cervical or endometrial polyps	Spotting after coitus, douching, or defecation; mucopurulent discharge	Often asymptomatic	Localized benign growths of endometrium/cervix	Polypectomy, histologic examination
Endometrial hyperplasia/cancer	Early brown or bright red bleeding, later heavier and frequent	Pelvic, rectal, lower back, leg pain; anemia; uterine enlargement	Unopposed estrogen → endometrial proliferation → abnormal shedding	Endometrial biopsy, hysteroscopy, surgery, chemo/radiation
Ovarian tumors (estrogen-producing)	Heavy bleeding not associated with coitus	Pelvic mass, breast enlargement, cervical mucus increase, spider angiomas	Estrogen excess → endometrial stimulation	Surgical resection, oncologic management
Vaginal cancer	Spotting after coitus; thin watery discharge	Ulcerated vaginal lesion, dyspareunia, urinary frequency, bladder/pelvic pain, rectal bleeding	Malignant transformation of vaginal epithelium	Biopsy, surgery, chemo/radiation

Other causes

Hormone therapy: Unopposed estrogen replacement can cause bleeding; often corrected by adding progesterone or adjusting estrogen dose.
Infections: Cervicitis or vaginitis.
Trauma or foreign body: Rare but should be excluded.

Special considerations

Perform diagnostic investigations:
- Transvaginal ultrasonography for uterine or cervical masses.
- Endometrial biopsy or dilatation & curettage with hysteroscopy.
- Colposcopy for cervical evaluation.
- Vaginal and cervical cultures for infection.
- Occult stool blood testing if gastrointestinal bleeding suspected.
Discontinue exogenous estrogen until diagnosis is clarified.

Patient counseling

Explain that most PMB is benign, but evaluation is essential.
Educate about reporting any new bleeding or associated symptoms promptly.
Discuss importance of follow-up and completion of investigations to rule out malignancy.

Geriatric pointers

Approximately 80% of PMB cases are benign.
All postmenopausal bleeding warrants evaluation according to the American Cancer Society.
Older women may have atrophic vaginitis or polyps as common causes.
Evaluate for malignancy in all postmenopausal women presenting with bleeding.

References

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Schuiling KD. Women’s Gynecologic Health. Burlington (MA): Jones & Bartlett Learning; 2013.
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American College of Obstetricians and Gynecologists. Postmenopausal bleeding. ACOG Practice Bulletin No. 149. Obstet Gynecol. 2015;125(6):1558-70.
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