Vaginal bleeding, postmenopausal

Vaginal bleeding, postmenopausal: Excerpt from Nursing: Interpreting Signs and Symptoms

Postmenopausal vaginal bleeding—bleeding that occurs 6 or more months after menopause—is an important, albeit not a definitive, indicator of gynecologic cancer. It can also result from infection, a local pelvic disorder, estrogenic stimulation, atrophy of the endometrium, and physiologic thinning and drying of the vaginal mucous membranes. Bleeding from the vagina may also be indicative of bleeding from another gynecologic location, such as the ovaries, fallopian tubes, uterus, cervix, or vagina. Bleeding usually occurs as slight, brown or red spotting developing either spontaneously or following coitus or douching, but it may also occur as oozing of fresh blood or as bright red hemorrhage. Many patients—especially those with a history of heavy menstrual flow—minimize the importance of this bleeding, thus delaying diagnosis.

History and physical examination

Determine the patient's age and her age at menopause. Ask when she first noticed the abnormal bleeding then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her menses regular? If not, ask her to describe menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient's mother and ask about a family history of gynecologic cancer. Determine whether the patient has associated symptoms and if she's taking estrogen.

Observe the external genitalia, noting the character of vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient's breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.

Medical causes

Atrophic vaginitis.When bloody staining occurs with atrophic vaginitis, it usually follows coitus or douching. Characteristic white, watery vaginal discharge may be accompanied by pruritus, dyspareunia, and a burning sensation in the vagina and labia. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Cervical cancer.Early invasive cervical cancer causes vaginal spotting or heavier bleeding, usually after coitus or douching but occasionally spontaneously. Related findings include persistent, pink-tinged, and foul-smelling vaginal discharge and postcoital pain. As the cancer spreads, back and sciatic pain, leg swelling, anorexia, weight loss, hematuria, dysuria, rectal bleeding, and weakness may occur and the drainage may become dark and malodorous.

Cervical or endometrial polyps.Cervical or endometrial polyps are small, pedunculated growths that may cause spotting (possibly as a mucopurulent, pink discharge) after coitus, douching, or straining to defecate. Many endometrial polyps produce no symptoms.

Endometrial hyperplasia or cancer.Bleeding occurs early with endometrial hyperplasia or cancer; it can be brownish and scant or bright red and profuse, and usually follows coitus or douching. Bleeding later becomes heavier and more frequent, leading to clotting and anemia. Bleeding may be accompanied by pelvic, rectal, lower back, and leg pain. The uterus may be enlarged.

Ovarian tumors (feminizing).Ovarian tumors producing estrogen can stimulate endometrial shedding and cause heavy bleeding unassociated with coitus or douching. A palpable pelvic mass, increased cervical mucus, breast enlargement, and spider angiomas may be present.

Vaginal cancer.Characteristic spotting or bleeding with vaginal cancer may be preceded by a thin, watery vaginal discharge. Bleeding may be spontaneous but usually follows coitus or douching. A firm, ulcerated vaginal lesion may be present; dyspareunia, urinary frequency, bladder and pelvic pain, rectal bleeding, and vulvar lesions may develop later.

Other causes

Drugs.Unopposed estrogen replacement therapy is a common cause of abnormal vaginal bleeding. This can usually be reduced by adding progesterone (in women who haven't had a hysterectomy) and by adjusting the patient's estrogen dosage.

Nursing considerations

▪ Prepare the patient for diagnostic tests, such as ultrasonography, endometrial biopsy, colposcopy, dilatation and curettage, and vaginal and cervical cultures.

▪ Discontinue estrogen until a diagnosis is made.

Patient teaching

▪ Reassure the patient that postmenopausal vaginal bleeding may be benign, but careful assessment is needed.

▪ Teach the patient about the underlying cause and its treatment.

Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7

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