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Question: I’m 56 and very healthy. I exercise six to seven times a week, eat organic and take a daily soy-based phytoestrogen supplement by mouth to combat vaginal dryness, as well as calcium, magnesium, vitamin D3 and a multivitamin. I’m 5’6” and weigh 135 pounds.

After 18 months of no periods, I find myself having one! It’s a light period that started out with brown fluid that has now become (the second day) red and it’s behaving like a light period. I have not heard of other women experiencing this. Is it something I should see my doctor for? –Marilyn

Dr. Pat: I am so glad that you asked this question. Unexpected bleeding is very common in the late perimenopausal and early postmenopausal years. Patients do not know if this is a return of “normal” periods, or if it’s something benign, or if they have a serious problem, since bleeding can be a symptom of endometrial cancer.

Certainly, this is not a period in the sense that you ovulated and then had the expected shedding of the endometrial lining 14 days after ovulation. What you have experienced is what we term “anovulatory bleeding,” which means it is not regulated by the usual cycle of ovulation.

I consulted Dr. Brian Slomovitz, assistant professor of gynecologic oncology at New York Presbyterian Hospital/Weill Medical College of Cornell University, to give you the most current opinion about this problem. His primary area of research is endometrial cancer.

Dr. Slomovitz noted that postmenopausal bleeding is defined as the resumption of any vaginal bleeding six months after one’s last episode of bleeding. His advice is that all women over age 40 who present with suspected anovulatory uterine bleeding should be evaluated with an endometrial assessment.

Evaluation of the uterine lining (the endometrium) is done by imaging the endometrium with pelvic ultrasonography and by taking tissue from the endometrial cavity. This is generally an in-office procedure, though it depends on the patient’s condition and symptoms.

Since every patient who is told that she needs evaluation for postmenopausal bleeding fears that she has endometrial cancer, I asked Dr. Slomovitz to comment on the risk of cancer in a patient with postmenopausal bleeding.

“This is a tough question to answer because the factors involved include access to medical care and patient awareness of symptoms,” he said. “Ninety percent of women with endometrial cancer have abnormal uterine bleeding, and between 15 and 20 percent of postmenopausal bleeding is caused by endometrial cancer or endometrial hyperplasia.”

It is important to get tested. Endometrial cancer, the most common form of uterine cancer, accounts for six percent of all cancers in women (recent data on treatment, prevention and rate of new cases [PDF] is available from the National Cancer Institute). Remember, early detection leads to more choices and improved chances for a better outcome. This applies to almost everything in life.

Endometrial hyperplasia occurs when the lining of the uterus grows too much. It can be treated in most cases. Though it is non-cancerous, some women with endometrial hyperplasia can be at greater risk of uterine cancer. The American College of Obstetricians and Gynecologists offers more information about testing and treatment.

In addition to scheduling an appointment with your doctor, I suggest that you stop taking soy-based phytoestrogen supplements, since you may be receiving too much estrogen. Unopposed estrogen in any form can lead to endometrial cellular hyperplasia or even endometrial cancer.

I know that you were using the soy phytoestrogen supplement to improve vaginal dryness. Once you have a thorough evaluation of the cause of this episode of postmenopausal bleeding, I suggest that you use a local vaginal estrogen in small amounts instead, if your gynecologist feels that this is safe for you. I sometimes recommend Vagifem, a low-dose bioidentical estradiol pill. Along with vitamin D and using a vaginal lubricant for intercourse, it should be a safer alternative to the supplement you are now taking.

After all, you do not know what is in your soy phytoestrogen pills. These supplements are not FDA approved and there are no standards established for safety or efficacy.

* * * * *
Dr. Patricia Yarberry Allen,
director of the New York Menopause Center, is a gynecologist affiliated
with New York-Presbyterian Hospital and a board certified fellow of the
American College of Obstetrics and Gynecology.
Have a question about sex, women’s health or the menopausal transition? Write to [email protected].

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