Vaginal Bleeding During/After Menopause and on HRT: Causes and Evaluation

Postmenopausal bleeding (PMB) or breakthrough bleeding on hormone replacement therapy (HRT) requires prompt evaluation to exclude malignancy.

Differential Diagnosis

• Atrophic changes: Vaginal/endometrial atrophy (most common cause of PMB).
• Endometrial hyperplasia/carcinoma: Risk increases with unopposed estrogen; must be ruled out.
• HRT-related: Breakthrough bleeding common in first 3–6 months of continuous combined HRT; persistent bleeding needs investigation.
• Polyps/fibroids: Cervical or endometrial polyps; submucosal fibroids.
• Infections/STIs: Cervicitis, vaginitis.
• Coagulopathy/anticoagulants.
• Malignancy of cervix, vagina, vulva.

Evaluation

• Transvaginal ultrasound (endometrial thickness >4 mm warrants biopsy).
• Endometrial sampling (pipelle, hysteroscopy with D&C).
• Cervical screening if due.

Management

Adjust HRT regimen (increase progestin, switch to continuous combined, consider Mirena IUS). Treat atrophy with vaginal estrogen. Refer urgently if cancer suspected.