25 July 2016 09:28:33

What every woman should know about postmenopausal bleeding and new HRT guidelines

Doctors call postmenopausal bleeding (PMB), any bleeding more than 12 months after a woman's last period if she is over the age of about 50. When should you worry about PMB and what's changed about the guidance for treating menopausal symptoms?

Bleeding from anywhere is scary, and vaginal bleeding once you thought 'that sort of thing' had stopped for good can be especially worrying. In fact, there's a good chance your doctor can reassure you - but you do need to get it checked out.

What is it?

Doctors call postmenopausal bleeding (PMB), any bleeding more than 12 months after a woman's last period if she is over the age of about 50 . But even that isn't the whole answer. If you have bleeding when you go to the toilet, it's important to try and work out whether it's coming from your back passage, vagina or waterworks.

Studies suggest confusing blood from the last two is especially common. They all need checking out by your GP, but it will help your doctor enormously if they know where it's coming from. If you're taking hormone replacement therapy (HRT) you may get regular periods, but check with your GP if you get significant bleeding more than four weeks after you stop HRT.

What causes PMB?

Every woman worries about cancer, but about 90% of women who have PMB can be reassured on testing there's no sinister cause. Your doctor will need to rule out cancer of the womb lining as well as cancer of the cervix. Some women have a polyp - a small, non-cancerous growth from the womb lining. Many others get PMB because of inflammation of the vaginal lining, caused by vaginal dryness after the menopause.

Will I need further tests?

You may need further tests if you get any heavy bleeding or more than one episode of light bleeding. These days, you can often be seen, have tests and (more often than not) get the all-clear in a single hospital appointment.

What tests will I need?

You'll have an examination and an ultrasound scan - this takes minutes and is painless, but you will need a very full bladder and you may need to have a small probe inserted into your vagina to get a good image for the ultrasound. You'll usually have a smear test too.

If the ultrasound is clear, you may not need any further tests. If the lining of the womb is thickened, you may need a small biopsy taken of the womb lining - you won't need an anaesthetic and while it's uncomfortable, it's over in minutes.

What's the treatment?

That depends on the cause. Polyps can be easily removed, and treating infection or inflammation caused by vaginal dryness should settle your symptoms. You may need no treatment at all - but whatever happens, getting your symptoms looked into is well worth doing.

HRT - is it good or bad?

There are two main kinds of HRT: 'normal' HRT, taken in the form of tablets, patches or occasionally implants, and 'topical' oestrogen cream.

HRT was very popular until about 13 years ago, because it often completely stopped the miserable hot flushes so many women get after the menopause. However, since studies suggesting a possible link with breast cancer, far fewer women take it. But further evaluation of these studies have put the risks into perspective.

Last year, the National Institute for Health and Care Excellence (NICE) brought out new guidelines on management of the menopause. They assessed all the evidence and put approximate figures on the risks:

  • There is a small increased risk of a clot on the leg or the lung
  • The risk of a clot on the leg or on the lung is smaller from HRT in patch, rather than tablet, form
  • For every 200 women taking combined HRT for five years, one may get breast cancer who wouldn't have done otherwise
  • HRT tablets but not patches may slightly increase the risk of stroke
  • Tailing off HRT rather than stopping abruptly may reduce the chance of hot flushes recurring in the short-term
  • SSRI antidepressants have been used in the past to treat menopausal symptoms, but shouldn't be used as a 'first line' treatment
  • HRT does not increase your risk of heart attack or stroke if it's started under the age of 60.

Unfortunately, no treatment works as well as HRT for hot flushes. These often settle within two to three years of the menopause, although it may take several years.

However, hot flushes may come back - usually just for a few months - when you stop HRT. If they do - or if you want to avoid HRT altogether - it may be worth trying herbal alternatives such as Menoherb® or Red Clover isoflavone (ask your pharmacist or at a health food shop).

Topical oestrogen cream has lower risks and can treat troublesome vaginal dryness, and new guidelines from NICE suggest the risks are extremely low, even in the long term. Alternatively, ask your pharmacist about Replens vaginal moisturising cream, which contains no hormones, for vaginal dryness.

With thanks to 'My Weekly' magazine where this article was originally published.

Dr Sarah is unable to provide medical advice or respond directly to questions concerning your health. If you have health concerns we recommend contacting your GP.