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A cancer warning that should not be ignored

Postmenopausal bleeding could be a sign of endometrial cancer, says Dr. Judith Reichman, and it should be taken seriously.

Q: I’m 54 and haven’t had my period for a year and a half, but now it seems to have come back within the last week. Should I be worried?

A: This could indeed be a worrisome symptom. If you’re not on hormone replacement therapy and haven’t bled for a year, doing so puts you in the diagnostic category of postmenopausal bleeding. This could be a warning sign for a type of uterine cancer called endometrial cancer, which develops in the uterine lining. It is the most common cancer of our reproductive organs, but, thankfully, is also the least fatal.

Testing for endometrial cancerThis situation mandates a visit to your gynecologist. (You can start with your regular healthcare practitioner, but a referral should be made.) You should then undergo a regular speculum exam to ensure that the bleeding is not due to a polyp or growth in the cervix. (I assume you’ve had regular Pap smears and they’re normal.) Your doctor may want to do an ultrasound to see if the uterine lining appears thickened or uneven, and she may even consider injecting fluid through a catheter into the lining during the ultrasound to see if there are polyps or fibroids projecting inward.

Unless your doctor can reassure you that the endometrium is thin (like a pencil line), an endometrial sampling should be performed. Usually, a narrow, hollow tube (canula) is inserted through the cervix into the endometrial cavity. This tube is attached to a syringe-like device used to suction out cells from the lining. Or, alternatively, a small amount of fluid can be inserted and withdrawn to obtain the cells. Many doctors will use a local anesthetic to make this more comfortable, though the procedure usually causes little more than short-term cramping.

The minute amount of tissue obtained during the sampling is then sent to a pathologist and checked for abnormal buildup of glands (hyperplasia), with or without cell abnormality (atypia).

Abnormality could mean cancerIf there is no sign of atypia, the bleeding you’re experiencing may have been caused by over-stimulation of these glands from your body’s production of estrogen. The latter does not stop simply because you are menopausal. Hormones produced by the adrenal glands can be converted to estrogen compounds by fat cells. The more fat cells you have, (in other words, if you are overweight or obese) the more hormones undergo estrogen conversion. If the stimulation is overly aggressive, the glands eventually become “confused” and atypia occurs.

Atypia can be a precursor to actual cancer and should probably be further investigated through a procedure in which a small instrument is inserted into the endometrium in order to see its entire surface, and further biopsies are taken. Or your doctor may feel a hysterectomy is the next best course of action. There is no question that if cancer is found, you should undergo a hysterectomy, at which time the ovaries and some lymph nodes should also be removed to see if the cancer has spread.  This can be done using a laparoscope if the cancer is diagnosed at an early stage.

Worst case scenarioGoing from out-of-the-blue bleeding to worst case scenario: if cancer has invaded a major portion of the uterine muscle or spread to other organs, then radiation, chemotherapy and/or high doses of progestin may be necessary.

Before you freak out, know that chances are, your bleeding is not cancer and may indeed be due either to “old” follicles in an ovary waking up and producing estrogen, or to atrophy (thinning) of the uterine lining or vagina, causing the erosion of a small blood vessel.

If, however, the diagnosis of endometrial cancer is made, take comfort in the fact that 96 percent of women who undergo appropriate therapy will be alive and without recurrence five years later.

Dr. Reichman’s Bottom Line: Postmenopausal bleeding can be a warning sign for uterine cancer. Don’t ignore it. Get thee to a specialist.

Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of .