Postmenopausal Bleeding: Targeted History
Menopause is all over the news and social media right now . . . as it should be. Women’s health and sexual/reproductive healthcare can be overly focused on pregnancy and fertility. Menopause care has been neglected because as a society and a healthcare system, we often prioritize reproductive ability while we don’t think as much about how women* thrive throughout their lives.
We’ll discuss other aspects of menopause management including hormones, metabolic health, and mental health elsewhere, but there are cause post-menopausal bleeding that are life-threatening and thus need to be diagnosed promptly but are often dismissed as atrophy. Let’s start with some normal physiology:
Menopause
Menopause is the natural cessation of menses. In the late reproductive stage, levels of follicle stimulating hormone (FSH) go up, while estradiol levels are steady. In the early menopausal transition, the intermenstrual interval changes by 7 days or more. FSH levels can be variable but tend to higher than the normal range. Patients may notice their periods are closer together or further apart. From there, as a patient enters the late menopausal transition, they begin to have cycles where ovulation does not occur and skip periods altogether, sometimes for several months in a row. Because the transition into menopause features irregular menstrual cycles, menopause is diagnosed retroactively, after a patient has gone 12 full months without periods and there is no other cause. Hormone levels can be helpful: In general, an FSH level over 25 IU/L is consistent with the late menopause transition. But levels of FSH and estradiol are highly variable from one person to the next, and even overtime for the same individual, so they are not diagnostic.
The median age for menopause is around 51 years old, but it can occur earlier or later. Naturally occurring menopause before age 40 is called primary ovarian insufficiency and between age 40-45 it is called early menopause.
While it is expected to have irregular periods in the perimenopausal period, once a full 12 months have passed without menses, they should not come back. Bleeding after menopause is NEVER normal.
Now that we have a framework for what’s normal, it’s time to get a set of structured questions to help you get a clear picture of what’s happening in your patient’s body.
Getting the History
As always, you’ll begin with your standards: past medical history, past surgical history, family history (particularly of breast, ovarian, uterine or colon cancer), past OBGYN history (age at menarche, menstrual history, pregnancy history, last pap smear and any history of abnormal pap results, history of sexually transmitted infections), medications (prescribed and over-the-counter, supplements), and allergies.
Have you ever had 12 full months without bleeding?
Step one in evaluating post-menopausal bleeding is confirming that your patient is truly in menopause. If the answer to this question is no (even if the client has gone 10 months or 11 months without bleeding), you are evaluating for a different clinical concern with its own differential diagnoses. Check out the series on abnormal uterine bleeding during the reproductive years for guidance.
When did the bleeding start? When and how often does it happen?
Once you’ve confirmed that your patient is actually menopausal, you want a sense of what their bleeding looks like. Does it only occur after penetrative vaginal intercourse or only after a bowel movement? Only on the tissue when they wipe after going to the bathroom? Responses may point you toward some gynecologic causes over others, or even away from other the genital tract altogether.
How many pads, pantiliners or tampons do you need to use per day when you have bleeding?
Occasional spotting suggests possible atrophy, infection or inflammatory vulvar disorders; while heavy bleeding with clots is more common with uterine cancers.
Are you sexually active? What does sex mean for you?
Pregnancy is not a concern in the menopausal period, but sexually transmitted infections still are! I intentionally do not ask my patients how many sexual partners they have. It doesn’t matter. I have diagnosed sexually transmitted infections (STIs) in people who had only had sex once in their lives, or who were in what they believed (up until the point I called to say they have Trichomoniasis) were monogamous relationships. True story: I will never forget my visit with a woman in her sixties who was referred post-coital spotting. She was given a urine test for gonorrhea and chlamydia that came back negative, but no pelvic exam, then advised to see her gynecologist to discuss estrogen therapy because her bleeding was “likely due to vaginal dryness from menopause”. But the history didn’t add up for dryness. She had gone into menopause five years prior and never had any bleeding since except for the past two weeks when she suddenly started to have pain and bleeding with sex. Why now? We discussed that urine testing is not the best method to detect STIs for women, and that there were more possible infections to test for beyond gonorrhea and chlamydia. She hesitated – “I have been married for forty years. If I test positive for something, we have a real problem!” I gently explained my thought process. I was not trying to make any assumptions about her relationship. This was just one possible cause that made more sense based on the timing of her symptoms than menopause, but it was up to her if she wanted to skip that part of my recommended testing. She agreed to a pelvic exam, which showed a strawberry cervix but no signs of vaginal dryness and a vaginitis panel, which came back positive for trichomonas. Luckily, she had snagged an appointment with me off the waitlist two weeks after the visit with her primary care, but it’s easy to imagine a situation where she waited longer, or got a prescription for estrogen that would not have helped. And of course, we still checked for the scary things that can cause bleeding after menopause. Shit happens, condoms break, people cheat – it’s not my place to judge. I ask this question to determine if it is appropriate for me to offer STI testing and then I move on.
Are you having any vaginal discharge? What does it look or smell like?
Again, infections (sexually transmitted or otherwise) can present with spotting or bleeding. So can cancer of the cervix or uterus. Details about the amount, color, texture, or odor of the discharge can help stratify how likely you think each of these diagnoses is.
Are you experiencing any vulvar or vaginal itching? Have you noticed any changes on the skin?
Aside from infections and atrophy, inflammatory conditions of the vulvar skin and vaginal epithelium can cause bleeding.
Any changes in bowel or bladder function?
As a gynecologist, it often feels like the uterus, ovaries and vagina can’t catch a break. Everyone likes to blame them for everything, but they have so many neighbors that can cause all the same symptoms. I’ve seen consults for postmenopausal bleeding that turned out to be constipation with hemorrhoids or an anal fissure or bladder cancer with hematuria. Just because the blood is coming from somewhere below the waist doesn’t mean it’s a gynecology problem.
Any recent trauma or injury?
This could be from a fall or other accident, related to intercourse or not (or related to things that tehnically count as sex that the client is reluctant to name as such. Another way to word this open-ended question can sometimes open the door to discuss possible causes that have not yet come up or the patient did not feel comfortable bringing up is “Has anything happened recently that you can think of that might explain the bleeding?”
So we’ve covered a brief review of menopause and 8 questions to help you gather information about what’s happening with your patient. In the next post, we’ll walk through our diagnostic categories for post-menopausal bleeding and map the possible responses to these questions onto each of those categories.
Thanks for reading! Have thoughts, questions, suggestions for future posts, or your own story to share? Drop a comment below - I’d love to hear from you.
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