What Counts as Postmenopausal Bleeding?
Postmenopausal bleeding (PMB) is defined as any vaginal bleeding that occurs 12 or more months after the last menstrual period. It can range from light spotting on underwear to frank bleeding resembling a menstrual period. Any amount of bleeding — even a single episode — counts, and none of it should be dismissed as normal.
What Causes Postmenopausal Bleeding?
The majority of cases (roughly 70–90%) have a benign cause:
- Vaginal atrophy (atrophic vaginitis) — thinning and drying of the vaginal walls due to declining oestrogen
- Endometrial atrophy — a thin, fragile endometrium that bleeds spontaneously
- Endometrial polyps — benign growths within the uterine cavity
- Cervical polyps — benign growths on the cervix
- Hormone replacement therapy (HRT) — breakthrough bleeding, particularly in the first 6 months
However, in approximately 10% of women presenting with PMB, the cause is endometrial cancer. This is why the clinical rule is absolute: all postmenopausal bleeding must be investigated until cancer has been excluded.
How Is It Investigated?
The standard investigation pathway is:
- Transvaginal ultrasound (TVUS) — measures endometrial thickness. An endometrial stripe ≤4 mm in a postmenopausal woman is reassuring and has a negative predictive value above 99% for endometrial cancer.
- Endometrial biopsy (Pipelle) — if endometrial thickness exceeds 4 mm, or if bleeding recurs despite a thin endometrium, a Pipelle biopsy is performed. This is a 5-minute outpatient procedure.
- Hysteroscopy — direct camera visualisation of the uterine cavity, usually combined with targeted biopsy. Indicated when Pipelle is inconclusive or when polyps are suspected.
When to See a Gynaecological Oncologist
You should seek specialist referral if your biopsy shows endometrial cancer or atypical endometrial hyperplasia, if imaging reveals a suspicious endometrial mass, or if bleeding persists despite normal initial investigations. A gynaecological oncologist provides the diagnostic precision and surgical expertise needed to manage these situations optimally.
For investigation of postmenopausal bleeding in Ahmedabad, contact Dr. Nishtha Tripathi Patel: +91 76988 00333.