The fight against PMB

Postmenopausal bleeding (PMB) or bleeding after menopause is a common problem being seen in women with increasing longevity, infections and also forgotten intra uterine medical device after surgical operations.

PMB happens due to ulcers, fibroids, abnormal uterine or cervix and infections. Endometriosis cancer is also one of the reasons for PMB, but not in all cases explains Dr Rooma Sinha, senior gynecologist, laparoscopic and robotic surgeon at Apollo Hospitals.

Q Why do some women bleed even after menopause? What is the incidence of these cases seen in India?

Bleeding experienced by women after the menopause is called post menopausal bleeding and we are seeing more cases because of longevity in the aging population. The reasons can be presence of polyps or fibroids, thin atrophic endometrium and endometrial cancer. Abnormalities of the cervix is also found to be one of the reasons for the bleeding.

The other reasons observed in clinical examinations are infections, underlying medical disorders like liver cirrhois, ulcers in uterovaginal section and forgotten intra uterine device in early surgery.

Q Do women immediately come to the doctor in these cases or do they wait for sometime before approaching the healthcare sector?

It is not normal to bleed after post menopause. Women with postmenopausal bleeding should always see a doctor in order to rule out serious medical problems even if there is spotting. However, 80 to 90 per cent of the women with post menopausal bleeding have benign conditions and can be treated with medication or surgery.

There are two categories of women, some who report the first episode and some who report after multiple episodes. Any bleeding experienced after one year of menopuase should be reported. It is important to rule out uterine cancer.

However women with risk factors like obesity, diabetes, taking exogenous estrogens, on tamoxifen (given for breast cancer) or women who attain menopause late have higher chance of cancer and early approach helps to detect early.

Q What is the diagnosis carried out in these cases?

The first line of investigation is Transvaginal Ultrasonography (TVS), which is recommended to assess the endometrial lining thickness. The normal cutoff is 4 mm, and any report more than 4 mm should be investigated. Endoimetrial biopsy is recommended preferably along with evaluation.

Q Are endometrial cancer and post menopausal bleeding related? What is the incidence of women in these cases suffering from endometrial cancer?

Postmenopausal bleeding, until proved otherwise, should be considered abnormal, except in those taking hormone replacement therapy.

Postmenopausal bleed is the most common symptom of endometrial cancer. Five  to 10 per cent of postmenopausal bleeding are reported to be endometrial cancer.

Q In the case of non-cancerous cells, how can the bleeding be controlled?

Postmenopuasal bleeding which are not due to cancer can be treated by medication or surgery. If bleeding is due to polyps, hysteroscopic polypectomy is required to remove them. In majority of the cases, these polyps are non-cancerous and hysteroscopic removal is sufficient. They subsequently do not require any hysterectomy.
Endometrial atrophy can be treated with hormones such as oestrogen cream. If post menopausal bleeding is due to endometrial hyperplasia, it is suggested to be treated with hormone treatment or hysterectomy. If post menopausal bleeding is due to hormonal replacement therapy, HRT may be decreased/stopped depending upon the condition.

Q Will it bleed even after taking the medications?

Yes, it may and in these situations sometimes one may need to go for hysterectomy.

Q Why does the utrine lining bleed and could it mean that there could be any other cancer in the body? If so what?

Endometrial bleeding is generally due to local pathology in the uterine lining. Presence of hormones secondary to ovarian cysts can also present as postmenopausal bleeding.

QWhat is the treatment for endometrial cancer? Which types of endometrial cancers are there and what are their treatments?

Endometrial cancer is treated with surgery (hysterectomy along with removal of both ovaries, pelvic and para aortic lymph nodes). If the disease is detected early then chances of cure are good. Some advance cases may require radiotherapy and chemotherapy.

Follow up after surgery is as essential as the surgery itself. Thus all women operated for uterine (endometrial) should also come for follow up check ups.

Dr Rooma Sinha, senior gynecologist, laparoscopic and robotic surgeon