Bleeding After The Menopausal Transition - What is Normal?

I get a lot of questions on the topic of bleeding (or lack thereof). Many women who are postmenopausal (one year with no menstrual period after the age of 45) and experience vaginal bleeding ask me when it's time to see a doctor. Others who are approaching menopausal age and have an IUD or are on birth control wonder how to determine their menopausal status without having a period. If you fall into either of these categories, I have some insight to share.

Postmenopausal Bleeding–When is it a Concern?

If you are a postmenopausal individual experiencing bleeding and you want to know when it's time to see a doctor, the answer depends on whether you are on menopausal hormone therapy (MHT) or not:

For postmenopausal women taking hormone therapy: 

If you started hormone therapy less than six months ago, your bleeding may be a result of your body adjusting to MHT. Forty percent of patients have unscheduled bleeding after beginning MHT. This bleeding occurs as a result of “waking up” tissue that has been sleeping for a while, and in most cases, it will resolve on its own. You should call your doctor and let them know so that they can monitor you closely. 

Any persistent unscheduled bleeding that continues beyond four to six months from the start of hormone therapy should be evaluated by your doctor. An evaluation should include a pelvic ultrasound to examine the endometrial cavity, and if needed, an endometrial biopsy. 

For postmenopausal women not taking hormone therapy: 

If it’s been one year or more since your last period and you are postmenopausal, any vaginal bleeding is considered abnormal and should be evaluated by your gynecologist as soon as possible. 

It’s critical too to note that undiagnosed abnormal genital bleeding is considered a contraindication for use of MHT. A contraindication is a specific condition or reason that a drug or procedure should not be used because it may be harmful to the person. You will want to get a proper diagnosis to determine why you are experiencing this bleeding before introducing any type of hormone therapy. 

The Question of Menopausal Status While on Birth Control

If you have an IUD or are on birth control, and you are wondering how to determine your menopausal status, you have a couple options:

Option 1: 

Because the hormones used in some contraceptives can produce a regular period, you may notice that you are having increasing symptoms during your “placebo pills”. You may stop your contraceptive hormones and see if symptoms begin.  If you decide to stop your hormonal contraception (and use another method of contraception if you don’t want to be pregnant) you may notice irregular periods or no periods at all and/or increased anxiety, night sweats, memory problems, unexplained weight gain, painful sex, and changes in hair. If you go one full year without a period, you have reached menopause.  The Greene scale, a questionnaire designed to measure symptom severity, is widely used as a tool for helping to identify treatment needs during the menopausal transition.  Rating your symptoms with this tool may help you to determine where you are in the transition and help you to determine your next steps.

Option 2: 

Bloodwork option:  I have the patient stop her hormonal contraception (and use a backup method if pregnancy is not desired) and in 4 weeks, check hormone levels.  If the level of follicle-stimulating hormone (FSH) is elevated above 50, it can indicate that she is postmenopausal. You can discuss the option of bloodwork with your doctor, but be sure to keep in mind that a single blood test that shows elevated FSH should not be considered a definitive diagnosis of menopause, and levels between 25 and 50 may be indicative of perimenopause - but should be checked 3 - 4 times over a few weeks for a perimenopause diagnosis.  Again, simply talking to the patient and believing her symptoms is usually adequate to make the diagnosis of perimenopause.

The Bottom Line on Bleeding

The bottom line is that any bleeding after menopause that isn’t happening during the four to six month window after initiating MHT should be taken seriously and checked out by a physician expeditiously. Your doctor will want to rule out endometrial or cervical cancer or atrophic vaginitis and/or genitourinary symptoms of menopause (GSM). Atrophic vaginitis is a common cause of postmenopausal bleeding and, if diagnosed, will be treated with topical estrogen therapy or lubricants/moisturizers.