Vaginal Bleeding After Menopause (Postmenopausal Bleeding)

Why bleeding after menopause needs checking

After menopause, estrogen levels fall and the uterine lining (endometrium) becomes thin and inactive, so bleeding should not occur. Bleeding is the earliest symptom of endometrial cancer in about 90% of women who have it. Because endometrial cancer usually causes bleeding while it is still confined to the uterus, prompt assessment leads to early diagnosis and high cure rates. Most of the time, however, the cause is benign.

Causes of postmenopausal bleeding

Vaginal and endometrial atrophy (most common)

Low estrogen makes the vaginal walls and endometrium thin, dry and fragile. Small tears or inflamed areas bleed, especially after sex or a pelvic exam. You may also notice dryness, burning, itching and pain during sex. See atrophic vaginitis.

Endometrial and cervical polyps

Polyps are small, usually benign growths of the uterine lining or cervix that can cause spotting or bleeding after sex. Most are harmless, but a small proportion of endometrial polyps contain precancerous or cancerous cells, so they are usually removed. See endometrial polyps.

Hormone therapy

Women taking menopausal hormone therapy, especially sequential (cyclical) regimens, may have expected withdrawal bleeds. Irregular bleeding in the first 3 to 6 months of continuous combined therapy is common. Bleeding that starts after that, or is heavy or persistent, still needs assessment. See hormone therapy bleeding.

Endometrial hyperplasia

Overgrowth of the uterine lining due to excess estrogen without enough progesterone. Risk factors include obesity, estrogen-only hormone therapy in women with a uterus, tamoxifen and PCOS. Hyperplasia with atypical cells can progress to cancer if untreated. See endometrial hyperplasia.

Endometrial cancer

Endometrial cancer is the most common gynecologic cancer in the US, mostly affecting women over 50. Risk factors:

• obesity (the strongest modifiable risk factor)
• older age and late menopause
• never having been pregnant
• diabetes and high blood pressure
• estrogen-only therapy, tamoxifen use
• Lynch syndrome or a strong family history of bowel or uterine cancer

Other causes

• cervical cancer, vaginal or vulvar cancer (less common)
• uterine fibroids, although these usually shrink after menopause
• infections of the cervix or uterus
• blood thinners
• tamoxifen, which can thicken the endometrium and cause polyps
• trauma or a foreign body, such as a pessary
• bleeding from the urinary tract or rectum that is mistaken for vaginal bleeding

Clues to the cause

Tests

1. History and pelvic exam: including a speculum exam to look at the vagina and cervix, and a cervical screening test if due.
2. Transvaginal ultrasound: measures the thickness of the endometrium. In women not on hormone therapy, a thin lining of 4 mm or less makes cancer very unlikely.
3. Endometrial biopsy: a thin tube takes a small sample of the lining in the office. It takes a few minutes and can cause cramping.
4. Hysteroscopy: a camera passed through the cervix to view the inside of the uterus and remove polyps or take targeted biopsies. Done if the biopsy is inconclusive or bleeding continues.
5. Blood tests: a blood count if bleeding is heavy.

Even with a thin lining on ultrasound, persistent or recurrent bleeding needs further evaluation.

Treatment

• Atrophy: vaginal moisturizers and lubricants; low-dose vaginal estrogen cream, tablet or ring, which is very effective and absorbed in tiny amounts.
• Polyps: removal by hysteroscopy, usually as a day procedure.
• Hyperplasia without atypia: progestin therapy (tablets or a hormonal IUD) and repeat biopsies; addressing weight and estrogen exposure.
• Atypical hyperplasia: usually hysterectomy.
• Endometrial cancer: hysterectomy with removal of the ovaries and fallopian tubes, sometimes with radiotherapy or other treatment depending on stage. Early-stage cancer has a high cure rate.
• Hormone therapy bleeding: adjusting the regimen after other causes are excluded.

Frequently asked questions

Is bleeding after menopause always serious?

Most postmenopausal bleeding is caused by harmless conditions such as vaginal atrophy or polyps. But because around 1 in 10 cases is due to endometrial cancer, every episode should be checked, even a single spot. Early assessment means any cancer is usually found at a curable stage.

What is the most common cause of postmenopausal bleeding?

Atrophy, the thinning of the vaginal and uterine lining from low estrogen, is the most common cause. Endometrial polyps and hormone therapy are also frequent. Endometrial hyperplasia and cancer are less common but must be ruled out.

Is spotting after menopause normal?

No. Any spotting, including pink or brown discharge, more than 12 months after your last period should be reported to your doctor. Light spotting is usually from a benign cause, but it is the same warning sign as heavier bleeding and needs the same assessment.

What tests are done for postmenopausal bleeding?

Doctors usually start with a pelvic exam and a transvaginal ultrasound to measure the endometrial thickness. An endometrial biopsy is often done, and a hysteroscopy may follow if needed. These tests can usually be completed as outpatient procedures.

Can stress cause bleeding after menopause?

Stress does not cause bleeding after menopause. Once periods have stopped for a year, the ovaries no longer produce cycles that stress could disrupt. Any bleeding has a physical cause, so it should always be investigated rather than attributed to stress.