Postmenopausal Bleeding at Age 68: Causes and Urgent Evaluation

Any vaginal bleeding >12 months after the final menstrual period is abnormal and requires prompt investigation. At age 68, the differential includes:

1. Hormone therapy (HT): Estrogen-progestin regimens can cause withdrawal or breakthrough bleeding. Dose/type adjustment may help.
2. Endometrial atrophy: Thin, fragile lining bleeds easily; common, benign.
3. Endometrial hyperplasia: Unopposed estrogen effect; risk factor for cancer.
4. Endometrial carcinoma: Most common gynecologic cancer; peak incidence 60–70. Presents as postmenopausal bleeding in 90%.
5. Cervical/vaginal pathology: Atrophic vaginitis, polyps, cancer.
6. Systemic/iatrogenic: Anticoagulants, tamoxifen, bleeding disorders, trauma.

Required Workup

• Pelvic exam, speculum exam
• Transvaginal ultrasound (endometrial thickness >4 mm warrants biopsy)
• Endometrial biopsy (office pipelle) or hysteroscopy with D&C
• Pap/HPV testing if cervical screening not current

Do not delay evaluation. Early endometrial cancer is highly curable.