Vaginal bleeding, postmenopausal
Vaginal bleeding, postmenopausal: Excerpt from Handbook of Signs & Symptoms (Third Edition)
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. Bleeding from the vagina may be indicative of bleeding from another gynecological location, such as the ovaries, fallopian tubes, uterus, cervix, or vagina. Bleeding from these areas exits the body through the vagina. It 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, 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, 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.
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 are asymptomatic, however.
Endometrial hyperplasia or cancer
Bleeding occurs early, 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)
Estrogen-producing ovarian tumors 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 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 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
Some 80% of postmenopausal vaginal bleeding is benign; endometrial atrophy is the predominant cause. Malignancy should be ruled out.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
More About Vaginitis
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- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Vulvovaginitis (Professional Guide to Diseases (Eighth Edition))
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