Postmenopausal bleeding (PMB) refers to any uterine bleeding in a menopausal woman (other than the expected cyclic bleeding that occurs in women taking sequential postmenopausal hormone therapy). It accounts for about 5 percent of office gynecology visits .
All postmenopausal women with unexpected uterine bleeding patients should be evaluated for endometrial carcinoma since this potentially lethal disease will be the cause of bleeding in approximately 10 percent (range 1 to 25 percent, depending upon risk factors) . However, the most common cause of bleeding in these women is atrophy of the vaginal mucosa or endometrium . In the early menopausal years, endometrial hyperplasia, polyps, and submucosal fibroids are also common etiologies .
The evaluation of postmenopausal women with vaginal bleeding will be reviewed here. Evaluation and management of premenopausal women with vaginal bleeding is discussed separately. (See "Differential diagnosis of genital tract bleeding in women" and "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women".)
Vaginal bleeding occurs in approximately 4 to 11 percent of postmenopausal women [5-8]. The incidence of bleeding appears to correlate with time since menopause, with the likelihood of bleeding decreasing over time. As an example in a study that asked 271 postmenopausal women to complete a daily record, the estimated incidence of bleeding fell from 409/1000 person-years immediately after the first 12 months of amenorrhea following menopause to 42/1000 person-years more than three years after menopause .
Abnormal bleeding noted in the genital area is usually attributed to an intrauterine source, but may actually arise from the cervix, vagina, vulva, or fallopian tubes, or be related to ovarian pathology. The origin of bleeding can also involve nongynecologic sites, such as the urethra, bladder, and rectum/bowel. Cervical stenosis may inhibit egress of blood from the uterine cavity; hematometra may result.