Vaginal bleeding, postmenopausal
Postmenopausal vaginal bleeding—bleeding that occurs 6 or more months after menopause—is an important indicator of gynecologic cancer. But 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. Sometimes, what appears to be bleeding from the vagina is actually bleeding from another gynecologic location—such as the ovaries, fallopian tubes, uterus, or cervix—that exits the body through the vagina. Vaginal bleeding usually occurs as brown or red spotting that either develops spontaneously or follows coitus or douching, but it may also occur as oozing of fresh blood or bright red hemorrhaging. Many patients—especially those with a history of heavy menstrual flow—minimize the importance of vaginal 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 periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any 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 if the patient has any associated symptoms and if she’s taking estrogen.
Observe the external genitalia, noting the character of any 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 in this disorder, it usually follows coitus or douching. The characteristic watery white 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 a 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.
Cervical or endometrial polyps
These small, pedunculated growths may cause spotting (possibly as a mucopurulent pink discharge) after coitus, douching, or straining at defecation. However, many endometrial polyps produce no symptoms.
Endometrial hyperplasia or cancer
Bleeding occurs early in these disorders; 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. It may be accompanied by pelvic, rectal, low back, and leg pain and an enlarged uterus.
Ovarian tumors (feminizing)
Estrogen-producing ovarian tumors can stimulate endometrial shedding and cause heavy bleeding that isn’t associated 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 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.
Special considerations
Prepare the patient for diagnostic tests, such as ultrasonography to outline a cervical or uterine tumor; endometrial biopsy, colposcopy, or dilatation and curettage with hysteroscopy to obtain tissue specimens for histologic examination; testing for occult blood in the stool; and vaginal and cervical cultures to detect infection. Discontinue estrogen until a diagnosis is made.
Geriatric pointers
About 80% of cases of postmenopausal vaginal bleeding are benign, caused primarily by endometrial atrophy. However, malignancy should still be ruled out.
Patient counseling
Reassure the patient that most cases of postmenopausal vaginal bleeding are benign and not cancer related.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Bleeding after sex
Read excerpts from these other book chapters related to Bleeding after sex:
Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Bleeding after sex
» Next page: Vaginal Bleeding (Field Guide to Bedside Diagnosis)
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