Post-menopausal bleeding must be viewed with concern and investigations should start at the earliest, says Dr Leelavathi Devadas
At times, women experience occasional spotting or even heavy bleeding during the post-menopausal period. Our women have an unfortunate tendency to sweep this problem under the carpet, either thinking that it is a harmless, transient phenomenon, or feeling too shy to reveal it to the others at home. By the time people come to know if it, it would probably be too late!
A woman normally attains menopause when she is about 45-47 years old. For nearly 6-8 months after this pause, there may occasionally be some irregular bleeding, but, any such episode beyond that interval should be considered seriously. It is imperative for her to consult a gynaecologist straightaway, and undergo the advised investigations on a war footing.
One of the less harmful causes of such bleeding is sepsis. A younger woman is shielded from the infective germs by the thickness of her vaginal lining, protective acidity of the vagina, and a healthy level of estrogen in her blood — all these being inter-related. In an older woman, where the level of estrogen is on the decline, the vaginal lining gets gradually thinned out, while the cells there produce less and less of lactic acid. This alteration results in enhanced alkalinity in the vaginal environment, which, in turn, encourages the unbridled growth of pathogens. The infection thus caused may later spread to the higher regions of the reproductive tract. The main symptom of these changes will be vaginal bleeding (sometimes spotting and sometimes heavy) accompanied by lower abdominal pain and other expressions of toxicity.
There is yet another condition which our women usually try to hide. Ordinarily, the uterus is supported and held up by certain ligaments and tissues, but as age advances,these props get lax. The slackness produces a slow descent of the organ, which goes by the name, ‘Uterine Prolapse.’ Because of the consequent exposure to the exterior, the uterus, specially its mouth, the cervix, falls prey to infection, and this is followed by frequent spotting. Here, the patient would, invariably,have had multiple deliveries, with hardly any healthy interval. The deliveries , would also have been mostly conducted at home, sans expert help.
Uterine polyps are also culprits in producing debilitating bleeding, though they are benign and easily treatable. Malignancy of the body of the uterus is more prevalent in developed countries, whereas that of the cervix is more often seen in developing countries, where the social health status is much to be desired. In the latter, post-coital bleeding is the disturbing signal of serious changes in the cervical cells. This, definitely is not to be ignored.
Some ovarian tumours bring about post-menopausal bleeding too. Careful pelvic examination and ultrasound scanning will surely help in their early detection. During the course of treatment of breast cancer with tamoxifen, PMB may by a reason for concern.
Hormone Replacement Therapy has been popular with women either in treating menopausal problems like hot flushes or post-hysterectomy, where, ovaries also have been removed.
Any irregularity in using the female hormones will invariably lead to post-menopausal haemorrhage. Playing with hormones is a dangerous game.
But above all, cancer of either the body of the uterus or of its cervix must be remembered. Both are amenable to treatment if discovered in the early stages.
Treatment of post-menopausal bleeding is comparatively uncomplicated if we find out the cause first. The prevalent anaemia must be tackled concurrently.
If the woman has been on HRT (Hormone Replacement Therapy), and if she has been rather irregular in following its regime, the use has to be corrected, modified, or tapered down.
If sepsis is diagnosed, after the usual investigations, suitable antibiotics are to be exhibited. Vaginal acidity may be maintained by the vaginal insertion of lactic acid tablets, draining. Hysterectomy will be needed in select cases. Small doses of estrogen, for a short while, will also help.
Surgery is the line of treatment in ovarian tumours. Radiation, chemotherapy are the other arrows in the expert’s quiver. They are useful adjuncts in treating malignancy.
Polys are easily removed vaginally, but ultimately, hysterectomy gives satisfying results. The solution to the problem of uterine prolapse is definitely surgical. Any lurking foreign body in the vagina is to be removed first. In carcinoma of the body of the uterus, the patient will also be suffering from hypertension, diabetes, obesity, etc. — all these are to be controlled in tandem. Cancer of the cervix requires more elaborate surgery, better combined with radiation and chemotherapy.
But one of the recognised preventive measures would be the treating of genital warts caused by the human papilloma virus. HPV is said to be one of the accused in the causation of cervical malignancy.
PAP smear is an extremely helpful tool in detecting uterine cancer. A regular PAP test in a woman past 35 years of age is mandatory in many countries. Biopsies must be thought of even when there is the slightest suspicion of malignancy.
In races where all men are circumcised, cervical carcinoma is very, very rare. So, circumcising the male partner has been advised as a preventive measure, as accumulation of smegma under the prepuce is suspected to be carcinogenic. Psychological stress is again another factor, so, suitable counselling must also be thought of.
Yes, post-menopausal bleeding must be viewed with concern and investigations should start at the earliest. Recent modes of treatment have vastly improved and they are extremely efficacious. These days, the fear factor need not come into the picture at all.