By Dr Edmond Edi-Osagie MB.BS, MRCOG, MD, Consultant Gynaecologist
Somewhere after 45, a great many women notice that their body has started behaving differently. Periods become unpredictable. Sleep is broken. Hot flushes arrive without warning. It is natural to put every new symptom down to the menopause, and very often that is exactly what it is.
But the menopause does not explain everything. Some of the symptoms that get filed under ‘just my age’ are signs of something separate, and a few of them need to be looked at promptly. Knowing the difference is what this guide is for. It is not another article about HRT. It is about the symptoms that deserve investigation rather than reassurance, and what that investigation actually involves.
What changes, and when
The menopause is a single point in time: the date of your last ever period, confirmed only once twelve months have passed without another one. Anywhere between 45 and 55 is typical. Around it sit three phases, and the symptoms that are normal in one are not always normal in the next.
Perimenopause
Oestrogen rises and falls unevenly. Cycles become shorter, longer or heavier, with hot flushes, night sweats, poor sleep, low mood and joint aches.
Menopause
Your final period, confirmed after twelve months without bleeding. Hot flushes and sleep disturbance are often at their peak around this point.
Postmenopause
Flushes usually settle, but lower oestrogen has lasting effects on the vaginal tissues, bladder, pelvic floor and bones.
Those lasting effects are the reason that later years gynaecology is a specialism in its own right, not simply a question of whether to take HRT. What follows is more important: the symptoms that sit outside this picture.
Bleeding after the menopause is never normal
If you read one section, read this one
Any vaginal bleeding twelve months or more after your last period needs prompt assessment. That includes light spotting, a pink or brown discharge, bleeding after sex, and a single episode that has not happened again.
Most postmenopausal bleeding has a benign cause. Thinning of the vaginal lining, a cervical or endometrial polyp, and a side effect of HRT are all far more common than anything serious. But around one in ten women with bleeding after the menopause will be found to have cancer of the womb lining, and it is highly treatable when it is found early. That is why NHS guidance treats it as an urgent referral and why no reputable specialist will tell you to wait and see.
Assessment is quicker and less daunting than most people expect, and it can all be done as an outpatient:
If you have had bleeding since your periods stopped, do not wait for your next routine appointment. Arrange an assessment now.
Symptoms often wrongly filed under menopause
Not every symptom in this list means something is wrong. Each of them, though, has a cause worth identifying, because each has a treatment.
The pattern in every case is the same. The menopause is a reasonable explanation, but it is not the only one, and a short appointment can tell the difference.
Pelvic organ prolapse
Prolapse is where the bladder, womb or bowel drops down into the vagina because the supporting muscles and ligaments have stretched. It is extremely common. Around half of women who have given birth have some degree of prolapse on examination, and roughly one in ten will have surgery for it at some point. Pregnancy and childbirth, the menopause, chronic constipation, a persistent cough and heavy lifting all contribute.
Specialists grade prolapse from one to four. The grade matters less than how much it bothers you, and a mild prolapse that causes no symptoms needs no treatment at all.
Slight descent
The organ has dropped a little but stays well inside the vagina.
To the entrance
The organ reaches the entrance of the vagina.
Beyond the entrance
It bulges outside, especially when you stand or strain.
Complete prolapse
The organ sits fully outside the vagina.
Where prolapse does cause symptoms, there is a clear ladder of options:
Urinary symptoms and quality of life
There are two main types of urinary incontinence, and they are treated differently, which is why an accurate diagnosis matters. Many women have a mixture of both.
Stress incontinence
Leaking when pressure rises in the abdomen: coughing, sneezing, laughing, lifting or running. Caused by weakened pelvic floor or urethral support. Supervised pelvic floor training comes first, with surgical options if that is not enough.
Urge incontinence
A sudden, overwhelming need to pass urine, sometimes with leaking, frequency and night-time waking. Caused by an overactive bladder muscle. Treated with bladder retraining, medication and, after the menopause, often vaginal oestrogen.
Women routinely put up with incontinence for years before mentioning it, planning their lives around toilets and avoiding exercise, because they assume it is an unavoidable part of getting older.
Effective treatment exists and it is not something to accept.
What a specialist appointment involves at this stage of life
A consultation in midlife follows a predictable shape, and knowing it in advance takes away much of the apprehension.
You should leave knowing what has been found, what it means and what the options are. If nothing is wrong, you will be told so clearly. Women who have not had a routine check for some years sometimes combine this with a well woman consultation, which covers screening, bone health and cardiovascular risk in one visit.
Later years gynaecology in Manchester and Cheshire
Dr Edmond Edi-Osagie is a Senior Consultant Gynaecologist whose work covers the investigation of abnormal bleeding, pelvic masses and pelvic pain. He sees patients privately in Manchester city centre and at The Alexandra Hospital in Cheadle, and you can book without a GP referral.
The approach to care after 45 is built around independence and quality of life. The aim is not simply to rule out serious disease, although that comes first, but to deal properly with the symptoms that quietly narrow a life: the bleeding that stops you travelling, the prolapse that stops you running, the bladder that dictates where you can go. Most of these have solutions that are far simpler than people fear.
Appointments are unhurried, investigations are arranged quickly and usually at the same visit, and you see the same consultant from first appointment to discharge. Fees are set out openly on our costs page.
Book a later years consultation
Whether it is bleeding that needs checking, a prolapse or bladder problem that is limiting what you do, or simply a midlife review, one unhurried appointment with a consultant is usually enough to give you answers and a plan.
To arrange an appointment, contact us or call 0161 244 8623.
Frequently asked questions
Is spotting after the menopause serious?
It needs to be checked, even if it was light and has not happened again. Most causes are benign, but a small proportion of women with postmenopausal bleeding have cancer of the womb lining, and it is very treatable when found early. A scan and, where needed, a lining sample will give you an answer quickly.
Can I still get fibroids after the menopause?
Existing fibroids usually shrink once oestrogen falls, and new ones are uncommon. A fibroid that appears to grow after the menopause, or one that causes bleeding or pressure symptoms, should be assessed, because growth at this stage is unusual and needs explaining.
Do I still need cervical screening?
Yes. In England, women are invited for screening until the age of 64, and you should continue to attend even if you have been through the menopause, are no longer sexually active or are using HRT. If you have missed invitations, a smear can be taken at a private consultation.
Is prolapse surgery the only option?
No. Most women start with pelvic floor physiotherapy, and many find that is enough. A pessary is a good alternative for women who want to avoid or delay an operation. Surgery is reserved for prolapse that is still affecting your life after these options, and it is one of several choices rather than the default.
This article is for information and does not replace individual clinical advice. If you have symptoms that concern you, arrange an assessment.