Bottom Line: Is your unexpected bleeding normal? Here’s how to tell.
If you’ve reached menopause, you probably thought that your days of any bleeding down there were over—but then you saw blood. You might have even panicked because you know that can be a sign of cancer.
But take a deep breath, says Frederick Friedman, Jr, MD, director of obstetrics at the Mount Sinai Health System in New York City. While there is a link between bleeding and cancer in the uterine lining (endometrial cancer), in 90% of postmenopausal women when bleeding occurs, it’s something else.
Note: Even if it is just spotting, any postmenopausal bleeding should prompt a visit to your doctor to figure out what is going on. If you can see your doctor while you are actively bleeding, it is easier to identify the cause.
That being said, here are some of the surprising reasons a postmenopausal woman can have bleeding…
You might not realize that you’re at risk for a sexually transmitted disease during this chapter of your life, but if you’re not in a longstanding, monogamous relationship, you are. There’s been a dramatic rise in STDs among older Americans in recent years. A lot of this can be traced to increased sexual activity because of drugs, such as Viagra, that make men more able to have sex, but that’s not the only reason for the increase—there’s a female connection, too. After menopause, vaginal tissue grows thin due to the lack of the female sex hormone estrogen, making it more prone to tearing, which can leave you more vulnerable to an STD. Gonorrhea, chlamydia, herpes and syphilis can all cause bleeding, especially early on. Other symptoms that may suggest your bleeding is an STD include discolored cervical mucus and pain during urination. Your doctor will ask for a urine sample or swab your cervical discharge and send it off to the lab for a diagnosis.
You may think the bleeding is coming from your vagina, cervix or uterus, but it may be trickling down from your bladder. That’s because bladder infections or the bladder condition interstitial cystitis can sometimes cause bleeding. Other clues include needing to go to the bathroom often and urgently and/or pelvic pain. A urine sample will identify a bladder infection. Additional testing may be needed for suspected interstitial cystitis including a biopsy of tissue from the bladder wall.
Polyps inside the uterus or cervical canal are fairly common, but the amount of blood they cause can be scary, especially after menopause. As your uterine lining thins due to the drop in estrogen, these polyps also grow thin, and your body may shed the surface of the polyp—causing the bleeding. It’s usually light spotting or staining, but at times it can be surprisingly heavy. Your doctor will run a series of tests including a sonogram to locate the polyp and likely remove it to make sure it’s not cancerous.
While vaginal or endometrial thinning can lead to postmenopausal bleeding due to atrophy or too little estrogen, being on hormone replacement therapy can do so for the opposite reason: The lining of the uterus—the endometrium—thickens, and then bleeds. In the peri-menopause, many women are still making some estrogen, which causes the lining to thicken due to cell growth. However, they might not be ovulating. Since progesterone is generally made by the ovary only after ovulation, the “unopposed estrogen” causes a very thickened lining of growing cells. This is called endometrial hyperplasia, this condition often occurs when a woman has too much estrogen and not enough progesterone to balance it out (hormone replacement therapy that includes both estrogen and progesterone can help avoid this). The uterine lining may shed in this circumstance for several reasons. If the lining is too thick, the build-up may outgrow its blood supply and be shed. Similarly, as the hyperplasia develops, the attachment of cells to each other weakens. It’s important to find out whether hormone replacement is causing your bleeding because endometrial hyperplasia has been linked to the development of endometrial cancer.
If you see blood on toilet paper or in your toilet bowl, it could actually be rectal bleeding from hemorrhoids. Other possible causes of rectal bleeding include a fissure or cut, a bacterial infection or inflammatory bowel disease. If the source of your bleeding turns out to be rectal, your doctor will likely suggest a stool test and, if it could be more than a hemorrhoid, possibly an imaging test such as a colonoscopy to find the cause.
Every one of the above causes of postmenopausal bleeding is far more common than uterine cancer, so again, if you’ve seen blood, don’t panic…but do see your doctor right away.
