Bleeding After Menopause? Don’t Ignore This (Endometrial Cancer Warning Signs)

If you’ve had bleeding after menopause, even light spotting or brown discharge, this episode is for you.

In today’s Gyno Info, I’m breaking down exactly how I evaluate postmenopausal bleeding, when to worry about endometrial cancer, and what the updated ACOG guidelines say about ultrasound, biopsy, and next steps.

Postmenopausal bleeding means any bleeding after 12 months without a period — and yes, even one episode matters. About 1 in 10 cases are linked to endometrial cancer. The good news? When we catch it early, it’s often very curable.

I’ll walk you through the real risks, what testing actually looks like, and when you can feel reassured.

If you’re experiencing postmenopausal bleeding, please don’t ignore it. And if you’re a clinician, this episode walks through exactly how I apply the latest guidelines in real life.

Let me know your questions in the comments — I read them.

You can write to us at Questions@GynoInfo.net

And follow us on Instagram @gynoinfo

Remember, any questions that I answer or information that I give you on this podcast are to be understood as information only, not treatment of your medical problems. While I'm a very knowledgeable gynecologist, I'm not your gynecologist who has talked to you and examined you personally and is therefore actually able to treat you.

So please consult your own healthcare professional with any medical questions or concerns.

Transcript

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Welcome to Gyno Info, Frank Talk with Dr. Burkey, the podcast dedicated to teaching everyday women what they need to know about their body and how it works to successfully deal with the healthcare system and communicate with their doctors. Each week, I'll provide you with new information and practical tips about gynecology and women's health care. I want to prepare you for your doctor's appointments by teaching you what to expect, what information your doctor will need to know from you, and what questions you will need and should ask her so you can be confident and make the most out of every visit. Gynefo will give you the knowledge you need to take charge of your health and do this in a clear and frank way that you can understand without having a medical degree. One episode at a time. So now let's begin. Hello. Welcome back to GynoInfo, the podcast about women's health in normal everyday language that normal everyday people can understand. No special medical words and no doctor speak. A special welcome to those who just discovered us and are listening for the very first time. And please take a moment now to subscribe to GynoInfo so you can get back to this episode in case you have to interrupt in the middle and would like to finish the podcast later on. The same episode might not always show up in your feed anytime soon. Today I'm going to talk about cancer of the endometrium, cancer of the lining of the uterus. The recommendation on how to make sure that a woman with postmenopausal bleeding does not have endometrial cancer have recently changed. I want to make sure that you know what your doctor should be checking according to the latest recommendations if you have bleeding or even just a little spotting after you've gone through menopause and are no longer supposed to be bleeding. As you already know, I spend quite a bit of time studying to make sure that the information in my podcast is always up to date with the latest science. I try to translate the latest scientific information into normal everyday language that normal everyday people can understand. I want them to know what to expect and what to ask for when they go and see their doctors or any other healthcare providers. Now back to so-called postmenopausal bleeding. Bleeding after you've gone through the menopause. After a woman has not had any periods at all for a whole 12 months, she is officially in the menopause and will be postmenopausal for the rest of her life. Some people also call this time in a woman's life the climate caric, though that term is getting a bit outdated in the English-speaking world. The time before menopause, before this very last period, is called the perimenopause or the perimenopausal transition. During the perimenopause, most women bleed irregularly, and that is completely normal. It may be annoying, not knowing when the next period will come, and it might be very heavy, and it can feel like two or three periods at once when you have not bled for a while. But it is really not a cause for alarm. But if all of a sudden you start bleeding, or only just spotting, or even just have a dark brown discharge or staining your underwear after you had not bled for more than 12 months, or 12 years, or any length of time after your final period, that is definitely not normal. It has to be investigated carefully by a specially trained doctor as soon as possible. Because up to one in 10 women with postmenopausal bleeding have cancer of the uterine lining, have endometrial cancer. A cancer that can be cured if found in time, but it will kill you if it's not found early enough. According to the World Health Organization, about 100,000 women in the world die of endometrial cancer every year. According to the American Cancer Society, about 15,000 of these 100,000 women live in the US. It is the fourth most common type of cancer among women in the United States, after breast cancer, lung cancer, and bowel cancer. In the world as a whole, endometrial cancer is number five after cancer of the cervix, which we know is really a sexually transmitted disease, as it is caused by a sexually transmitted virus called human papillomavirus. For more of the HPV virus and cervical cancer, please check out episodes 126 that I posted in January of this year. The good news about endometrial cancer is that after everything is carefully checked out, about 9 in 10 women will be bleeding from something else, not from cancer. I will discuss later in this podcast what things other than endometrial cancer can cause postmenopausal bleeding. There are several major risk factors for endometrial cancer. The absolute biggest risk, of course, is obesity. And estrogen after menopause is mostly produced in fat cells. Before menopause, estrogen is produced by the ovaries during the normal menstrual cycle, making the lining of the uterus grow. In the second part of the menstrual cycle, the ovaries then produce a hormone called progesterone, which organizes the period, the shedding of the lining of the uterus, before a new lining begins to grow in the next cycle. After menopause, estrogen hormones are produced in the fat by changing other hormones into estrogen. And the more fat there is, the more estrogen is being produced, and the more the cells in the lining of the uterus are pushed to grow. But after menopause, there is no progesterone being made to organize a monthly clean out of that lining in the form of a regular menstrual cycle. Because of that, the lining of the uterus is kept growing and growing, and the cells get older and older, and in time can become more and more abnormal until some of them sometimes can turn into cancer. This type of endometrial cancer is actually a non-aggressive cancer, was a good prognosis, a good result if caught and treated early enough. It is not even particularly hard to treat. For these early non-aggressive endometrial cancers, removing the uterus by surgery or by hysterectomy is usually all it takes to cure somebody. Additional surgery, chemotherapy, and radiation treatments are only needed for the more aggressive and high-risk subtypes and the more advanced stages of endometrial cancer. 80% of endometrial cancers are of the non-aggressive type, which is definitely a piece of good news. The other piece of good news about these recently from type 1 endometrial cancer to non-aggressive endometrial cancer, renamed cancers, is that normal weight and physically fit women are much less likely to get this type of cancer. There is a good way to help prevent it: eating well, exercising a lot, and staying slim and fit. That actually causes just about every single type of cancer, especially breast cancer and bowel cancer, the number one and number three deadliest cancers in women worldwide. It also lowers the risk of sugar diabetes, heart disease, strokes, and many other diseases. Being obese, being overweight is more and more a sign of being poor, especially in rich countries, but in many not so rich countries now as well. Once poor women are no longer at risk of starving, they tend to get overweight anywhere in the world. This has many reasons, but one of the main reasons for that is that the poorer a woman is, the less time and ready cash she has to live healthily, to buy good food, and to exercise. Black women in the US are more likely to be poor, and because of that, they are more likely to be obese. And because of being obese, overweight, they're more likely to develop endometrial cancer. And because, like all women around the world who are poor, they have less access to good medical care, then they are more likely to not get the diagnosis of cancer early enough when it still could be treated. Often, they never even get the right diagnosis at all. Because of that, they are more likely to die when they get endometrial cancer. And in the US, because of the disgusting racism in the US healthcare system, when they finally do get care, it is worse care than the care that a white woman would get for the same medical problem, whether they are poor working class women or rich black celebrities or black sports and movie stars. This even holds for black doctors and other healthcare professionals when they become patients. Being black rather than white is a clear and proven health hazard in the US, no matter what social class or profession you belong to. I've talked about racism and sexism in the US healthcare system and inequality in access to healthcare in the world as a whole before. One of these days I will make a whole podcast about it, but that's for another day, not today. I just always get so furious when I look at these statistics, and then I start ranting. Black women in all parts of the world also tend to be more likely to have the now officially renamed aggressive, in the past, it was called type 2 subtype of endometrial cancer, which, as the name says, is more aggressive and more likely to be deadly, even with excellent medical care. So genetics do play their part, something that is being researched very much right now. It is even beginning to look like the stress of being poor can actually change the genetics of your body and may make you more prone to get many diseases, not just cancer. We will hopefully know more about this mechanism in a few years. Studies do show that the higher death rate in black women also has to do with race, not just racism. But in the US at least, racism is the more important and the key factor, even more so because it would be completely preventable. There are other factors that might put a woman at higher risk of endometrial cancer, not just obesity. For the recently renamed more aggressive subtype of endometrial cancer, it is also several other types of genetic mutations that increase the risk. Some of them are linked to breast cancer, but also other types of cancers that run in families. For the now called non-aggressive lower-risk endometrial cancers, the risk mostly have to do with estrogen and also with non-counteracting that estrogen with progesterone. One way of having too much estrogen is being obese, as I just explained. But another way is taking only estrogen without progesterone for postmenopausal hormone treatment when you still have a uterus with a uterine lining, an endometrium that should be periodically cleaned out. But it is not when you take your menopausal hormone treatment that way without progesterone. In fact, women who are taking both estrogen and progesterone for their menopausal hormone treatment have a lower risk of endometrial cancer than those who are taking no hormones at all. Another medication that acts like estrogen on the lining of the uterus, the endometrium, and also increases the risk of endometrial cancer is tamoxifen. Temoxifen is a medication that is used in the treatment of breast cancer. And lastly, there are tumors that produce estrogen. They also increase the risk of endometrial cancer. And now, before I get to the new recommendations on postmenopausal bleeding and the diagnosis of endometrial cancer, a few words on endometrial cancer before menopause. I just talked about how important the hormone progesterone is in preventing cancer of the endometrium. There are women before menopause that do not make progesterone. Any woman that for one reason or another doesn't ovulate, and because of that does not make progesterone to organize the regular monthly clean out of the endometrium during a regular menstrual period. This is called anovulation, not ovulating. And when you don't ovulate, you don't make progesterone. When women who do not ovulate are very obese, then they also produce a lot of estrogen in their fat, estrogen that is not countermanded by progesterone. A typical condition when that happens is polycystic ovary syndrome, PCOS. Women with polycystic ovaries are at very high risk of endometrial cancer. If you want to know more on PCOS and why women with PCOS usually are very much overweight, you might want to check out the three podcasts on PCOS, E130 and E131 and E132 that I just did last February. Now let's talk about the new recommendations on how doctors should deal with postmenopausal bleeding. According to current recommendations and guidelines in most countries, the first step, as always, is to talk to the patient and find out everything about the bleeding and doing a complete gynecological exam. This should, of course, be the first step not just for postmenopausal bleeding, but also for most other problems that bring a woman to the gynecologist. The next step should be to do a transvaginal ultrasound exam to check how thick the lining of the uterus is. The guidelines, including the ones by the American College of Wibby GYN, say that if the endometrial can be seen well, is very thin, less than 4 millimeters, and this is the very first time a woman has postmenopausal bleeding and has no risk factors for endometrial cancer, like the ones we just talked about earlier in the podcast, then no further procedures are needed because the chances of it being cancers when the lining is that thin are very, very small. However, and that is the new part of the updated guidelines by the American College of OBGYN, that now stress very clearly that if the endometrium cannot be seawell, which is the case in about a third of all women with postmenopausal bleeding, then an endometrial biopsy should be done right then and there. This is because studies have shown that if it's not done right then, many women will be lost and end up not coming back for a next appointment and having the biopsy that they urgently need. An endometrial biopsy is a procedure where a very thin plastic or metal tube is inserted through the opening of the uterus and a small amount of cells and tissues is sucked out that then can be sent to the lab to be examined for cancer cells. You can see this on the slide here if you're watching this podcast on YouTube. As you can imagine, it is not particularly comfortable, about like putting in an IOD or like a strong period cramp, but it only lasts a few seconds. The new guidelines by the American College of Obstetrics and Gynecologists clearly recommend that if a woman has strong genetic risk factors, or is very obese or is black, which puts her at higher risk for more aggressive subtypes of cancer, or has sugar diabetes, or has been bleeding more than just once, even if the lining looked thin on ultrasound at the first time of bleeding, she needs either an endometrial biopsy in the office, or if that cannot be done, she needs to be taken to the operating room to get one done. In all these situations, cells and tissue from the inside of the uterus have to be examined to make sure there is cancer or not. As I said earlier in this podcast, about 90%, nine out of ten women with endometrial cancer indeed do have postmenopausal bleeding or spotting as an early warning sign. So obviously, it is very important that postmenopausal bleeding is taken seriously and checked out right away and as soon as possible. But after checking it out, doctors will find endometrial cancer only about in one out of ten women. That is the good news. The other nine out of the ten women will be bleeding from a lining that is super thin and fragile. The treatment for that actually would be a little bit of natural estrogen to help it heal. They could also be bleeding from polyps, benign tumors from the lining of the uterus, or from fibroids, benign tumors of the uterus in the muscle right next to the lining that makes it bleed. Or they may be bleeding from lining that has gotten thicker and may or may not yet have abnormal looking cells in it, but that have not turned into cancer yet. The treatment for this last condition is simply making the lining shed and cleaning out the uterus by giving progesterone. This brings us to the end of the episode on postmenopausal bleeding and what to do when it happens. I hope you find this podcast gave you some new insights and information, and that you found it useful and will share it with as many other women as you can. Remember that if you have any further questions about postmenopausal bleeding or menopause overall or any other topic to have to do with women's health, please don't hesitate to send them to me at questions at gynoinfo.net. And again, that's questions at gynoinfo.net. And please also make sure that you click the subscribe button. Wherever you listen to or watch gyneoinfo so you can get back to it easily, whenever and wherever you want. And the more people subscribe, the easier it will be for others to find us. Thank you. Until next time. Thank you for listening. And remember that you and your health are super important and deserve your full attention. Don't ever put off contacting your doctor because you're scared or embarrassed when something feels wrong about your body. Doctors are here to help you, not to judge you. And also, regular Well-woman visits are always a good idea that you should make time for. You deserve it, and you owe it to yourself, and you owe it to your body and your health. This podcast is part of Pride House Media, hosted by me, Dr. Burke, produced and edited by Josh Rosenzweig, original music composed by Nell Balaban. If you enjoyed this episode, please subscribe wherever you listen to podcasts. And while you're there, leave us a rating and a review. It really helps others discover the show. Stay connected and join the conversation by following me on Instagram and Facebook at GynoInfo and on LinkedIn at gynoinfopodcast.