Hello Doctor,

I hit menopause like a year ago but I have been spotting for the last two weeks. I am seeing some drops of blood but there are no other signs to convince me that they are menstrual periods. What could be my problem? Should I see a gynecologist or is it a minor issue?

Leonie M, Gisozi

Dear Leonie,

Spotting of few drops of blood can occur few times after menopause but it usually stops after 6 months. Bleeding in any form or quantity occurring more than 6 months after the menstruation stops usually indicates some problem.

It can be due to any minor trauma such as scratching the vagina with nails.  Due to the small injury, a little bleeding can occur.  

This will subside in few days. Infection in the vagina or uterus or parts around it can also result in vaginal bleeding after menopause. In this case, one is likely to have pain in lower abdomen and painful sexual intercourse. Suitable antibiotics can cure this condition.

Polyps (non-cancerous growths) in the uterus, cervix (lower end of uterus) or vagina also result in vaginal bleeding after menopause. They are curable by surgery.

If the spotting is associated with frequency and urgency of urination, it can be due to severe cystitis (infection of the urinary bladder). If such a problem exists, you would have   other symptoms associated with   spotting. The drops of blood would have been passed only while passing urine and not otherwise.   Diagnosis is by microscopic examination of urine and suitable antibiotics can treat it.

At times due to hormonal changes after menopause the inner lining of uterus can become very thin and stretched out resulting in mild vaginal   bleeding.   Alternately there can be hyperplasia and the lining of uterus can become thick and this can be associated with postmenopausal spotting.

Women who are on blood thinning drugs like aspirin, clopidrogel or warfarin for any indication, can have spotting after menopause as side effect of these drugs. Those on estrogen therapy after menopause due to osteoporosis or any other reason may also develop vaginal bleeding due to secondary adverse effect of estrogen therapy.

The most sinister cause of postmenopausal bleeding is cancer. Cancer of the uterus, cervix or vagina causes postmenopausal bleeding as one of the manifestations.  

The malignancy may be primary to these parts or may have spread from some other adjoining part. Here the bleeding or spotting is painless. By the time the cancer is diagnosed it is usually well advanced and may have spread locally to surrounding body parts or through blood to other body parts.

Diagnosis is established by biopsy, colposcopy and PAP’s smear. Treatment is by surgery, chemotherapy and radiotherapy. The decision as to which form of therapy has to be employed singly or in combination rests with the gynecologist depending on the extent of spread of disease and general condition of the patient.

My advice is you do consult a gynecologist for your problem and get investigations done. 

Dr Rachna Pande is a Specialist in Internal Medicine in Ruhengeri Hospital