I entered menopause 2 years ago and yesterday I found


Q: I entered menopause 2 years ago and yesterday I found I was bleeding. I had vaginal ultrasound and endometrium line is 3 mm.
I had gastric bypassa 8 months ago and lost 51 quilograms.
I'm terrified with the possibility of have endometrial cancer but I read that a dramatic weight loss can be the cause for post menopause bleeding.
I'm 51 years old.

Symptoms:  Post menopause bleeding

A:   Hello,
Thanks for the query to ATD for an opinion,

I understand your concerns regarding endometrial cancer following an episode of post menopausal bleeding after 2 years of menopause. But the fact is there can be multiple causes of post menopausal bleeding and endometrial carcinoma can be just one of them.
1. The most common cause for post-menopausal bleeding is atrophic vaginitis, which is an inflammation of the lining of the vagina, caused by lower levels of oestrogen.
2. The second most common causes of bleeding post menopause are polyps and fibroids. Polyps and fibroids can occur in the uterus, and may cause irregular post menopausal bleeding, and are usually harmless
3. Endometrial atrophy is when the lack of oestrogen causes thinning of the lining of the uterus. It also causes the small blood vessels in the uterine lining to break down, and is similar to when a severe cold causes the lining of the nasal passages to break down, resulting in spontaneous bleeding.
4. Endometrial Hyperplasia is a condition where overgrowths of the uterine lining develop. This can cause post menopausal bleeding, and can sometimes turn cancerous. If caught early, it is treatable with progesterone, but if left, severe cases can result in a hysterectomy being required.

Not all cases of post menopausal bleeding are caused by a medical problem. Sometimes lifestyle and stress levels can have an effect on the body, causing bleeding to occur.

1. Dramatic weight loss can lead to oestrogen, normally stored in fatty tissues, being released into the bloodstream, leading to bleeding in the same way that hormone replacement treatment does. To avoid this, post menopausal women are recommended to lose weight gradually.

2. Emotional stress seems to have ties to post menopausal bleeding. Many women have reported spontaneous bleeding at times of extreme anxiety or excitement.

The only way to determine the cause of most cases of post menopausal bleeding is by a thorough gynaecological examination. This usually involves a range of tests :-
1. An ultrasound pelvis especially transvaginal, which you have rightly done, for estimating the endometrial thickness which should be less than 4mm in post menopausal status ( as is yours) to rule out any hyperplasia or endometrial cancer. An Endometrial thickness of 3mm in your case rules out endometrial cancer, so you may feel relieved.
2. Hysteroscopy may be done to look for any endometrial pop or fibroid and also for taking a biopsy of the endometrium.

In your case, it is indeed the dramatic weight loss which has probably caused this single episode of vaginal bleeding. It is suggested that you should maintain observation for a repeat episode which if occurs shall demand a thorough gynaecological examination. At present the cause is not hyperplasia but dramatic fat loss.
I hope I have answered your query in detail ,

Wishing you good health,

Comments / Follow Ups

Patient: Thank you very much for your answer.
Meanwhile my gynecologist phoned me and, regarnding my great anxiety, he proposed I make histerostomy tomorrow and biopsy. He assures me that is not he's concerned with cancer probabilitu but for me to be calm.
I didn't told you but and I'm a midwife and ginecology nurse and friend of my doctor.
You're answer is preciousto me because I never heard that weight loss could triggers post menopause bleeding. Although, bariatric surgery is recent and normally performed in younger woman.
My doctor didn't find polips or anything "different".
Thank you very much for your answers - precious in this time for me.
Best regards,

Doctor: I appreciate it . Thanks .
I wish you good health.
Patient: Hello again.
In November I bled again, my ginecologist had another ultrasound pelvis and still an endometrial line of less than 3 mm.
Then, what e found different was micropholiculae in te ovariums wich lead him to conclude that I may have no entered menopause. But serum estrogenios and and the other hormones are very low (indeed they were very low since I was 38). My cervix was too thin and dry and I was on vaginal pills for some weeks. He told me that is a 3rd episode ocurrs I'd be submitted to a histeroscopy and biopsy. After some days, it stopped until yesterday when bleeding appeared again. I'm scarred to dead. Being a maternal a,nd obstetric nursing teacher I think it can be the worse.
Now I want to have that hysteroscopy (in May when I forst emailed you I had Pipelle) and biopsy but in Portugal (public hospital, must wait) will take a couple of weeks.
What is you opinion about all this, now?
Can this still be perimenopause menstrual episodes?
Is this common? I know nobody who happened this (or they bleed and bleed always, or stop forever).
Being endometrial cancer was it supposed to don't reveal at Pippelle? 8 months is too much to have a cancer witout treatment. I feel terrified of being a cancer that turned to be invasive without treatment.
Your answer will be very much appreciated.
Thank you.
Doctor: Hello,
Considering the fact that you were without your menses since last 2 long years , so by definition as well you become menopausal and any bleeding post that would be termed as menopausal even though the micro follicles may be seen in the ovaries, which is possible but again there would not be any ovulation as those follicles will not grow. The levels of FSH & LH ( high values more than 25) SHALL CONFIRM MENOPAUSE AGAIN SO YOU MAY OPT FOR CONFIRMATION.
The present bleeding episode should any how be investigated with hysteroscopy this time after a repeat ultrasound pelvis report and an endometrial biopsy should as well be taken. Secondly cervical and vaginal causes of bleeding should also be ruled out in terms of any growth per se, which can possibly bleed.
Patient: Thanks for your answer.
Can you please clarify to me what do you mean: "Secondly cervical and vaginal causes of bleeding should also be ruled out in terms of any growth per se, which can possibly bleed."
And my question: can this be cancer in spite of the negative Pipelle? And if so, 8 months without treatment is to much time and can be invasive no?
Doctor: Yes it can be a cervical or a vaginal cancer and not endometrial or uterine cancer which can be the cause of bleeding as well. And yes if its a cancer then 8 months would indeed by ample time for invasion. Hence please get yourself examined thoroughly.

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