Bleeding After Menopause: Causes, Diagnosis & Treatment

Bleeding after menopause, also referred to as postmenopausal bleeding, is any vaginal bleeding that occurs after you’ve stopped having your menstrual cycle for 12 months in a row. The bleeding can vary in intensity, from light spotting to a heavier flow.

Although postmenopausal bleeding is somewhat common—around 10% of people report vaginal bleeding after menopause—it’s not normal and can be a sign of underlying health issues. It’s important to consult with a healthcare provider as soon as possible if you have postmenopausal bleeding.

Several health conditions can cause postmenopausal bleeding, from physical tears in your vaginal walls to cancer. No matter the cause, vaginal bleeding after menopause is always something to be taken seriously.

Vaginal Atrophy

About 60% of vaginal bleeding after menopause is caused by vaginal atrophy, a condition caused by the declining levels of the female reproductive hormone estrogen during and after menopause. With vaginal atrophy, tissue in the vaginal walls becomes thinner, drier, and less elastic. This thinning can lead to minor vaginal bleeding or spotting, especially after penetrative sex.

Endometrial Atrophy

Endometrial atrophy occurs when the lining of the uterus (the endometrium) gets thinner due to decreased estrogen levels in your body. Over time, the lining may get too thin, which can trigger bleeding.

Polyps and Fibroids

Polyps and fibroids are non-cancerous growths. They’re usually harmless, though they can cause a range of symptoms, including vaginal bleeding.

Polyps cause approximately 30% of postmenopausal bleeding. Endometrial polyps, or uterine polyps, are growths that form in the uterus lining. These growths contain tissue and blood vessels that can be small or large enough to fill the uterine cavity. 

Fibroids are benign (non-cancerous) tumors that grow in the uterus. Fibroids can stimulate the growth of blood vessels in the uterus or cause the uterine lining to thicken. Both situations may cause vaginal bleeding. However, fibroids usually shrink and don’t cause any symptoms after menopause. So more often, polyps would be the cause of the bleeding rather than fibroids.

Endometrial Hyperplasia

Endometrial hyperplasia refers to a uterine lining that is too thick. The thickening is often caused by a hormonal imbalance, where there is too much estrogen without enough progesterone (another female reproductive hormone) to balance out the estrogen.

If left untreated, the thickened lining can produce abnormal cells. These abnormal cells can turn into growths that are either benign (noncancerous) or pre-cancerous. 

Abnormal bleeding, such as bleeding in people who’ve gone through menopause, is the most common symptom of endometrial hyperplasia.

Endometrial Cancer

Endometrial cancer is a cancer that affects the endometrium (the lining of the uterus). About 90% of people diagnosed with endometrial cancer reported postmenopausal bleeding as the first symptom that led to their diagnosis. The bleeding may vary in flow and can even be spotting.

Besides abnormal bleeding, you may experience lower abdominal pain or pelvic cramping if you have endometrial cancer.

Because you’re no longer having a menstrual cycle, any bleeding after menopause is abnormal bleeding. It’s important to see a healthcare provider at the first sign of postmenopausal bleeding. The earlier your provider diagnoses the cause, the more likely the outcome will be favorable, regardless of the underlying condition.

When you see your healthcare provider, they may perform or order various tests to help make their diagnosis. These tests may include a biopsy, an ultrasound, or other lab tests. In addition to diagnostic tests, you can expect your healthcare provider to ask questions about your personal and family medical history.

Physical Exam

Your provider will likely perform a physical examination during the diagnostic process, including a pelvic exam.

During a pelvic exam, your provider will try to identify the source of bleeding, such as lesions or tears, or signs of atrophy, such as pale, dry tissue. They will also look for signs of inflammation, such as redness; small red spots; or thin, fragile tissue. If your provider finds signs of irritation or inflammation, the bleeding may be related to atrophy.

Your provider will also likely feel for masses or growths during a pelvic exam.

Endometrial Biopsy

During the pelvic exam, your provider may take a small sample of tissue from your uterus in a procedure called an endometrial biopsy. The American College of Obstetricians and Gynecologists considers biopsies a first-line test for postmenopausal bleeding in people at high risk for cancer.

Taking a tissue sample helps your provider detect abnormalities, including cancerous cells.

Transvaginal Ultrasound

A transvaginal ultrasound is another first-line diagnostic tool, especially if your medical and family history put you at low risk for cancer. Providers can also use this ultrasound to confirm the results from your biopsy by taking a closer look at your uterus. During the imaging test, your provider will look at the thickness of your uterine lining.

If the lining is thicker or shows signs of polyps or fibroids, further testing, like hysteroscopy (a thin telescope that is inserted into your uterus through the vagina and cervix), may be needed for a closer look.

If the ultrasound doesn’t give clear results or doesn’t show the cause of bleeding, your provider may recommend other imaging tests, such as magnetic resonance imaging (MRI), to get a detailed view of your uterus.

Laboratory Tests

Additional laboratory tests can help your healthcare provider diagnose postmenopausal bleeding. This may include different types of blood tests.

Your healthcare provider may also want to perform a Pap smear. While Pap smears can’t diagnose postmenopausal bleeding, they can detect related abnormalities, like cervical infections or cancers, that might contribute to the bleeding.

Treatment options can vary depending on the underlying cause of the bleeding.

If the cause is vaginal atrophy, sometimes a vaginal lubricant can significantly improve the irritation and inflammation that contributes to postmenopausal bleeding. Your healthcare provider may also prescribe topical estrogen to help decrease symptoms.

If polyps or fibroids cause the bleeding, the common treatment plan is surgical excision, where a surgeon removes the growths.

Treatment for endometrial hyperplasia varies. Benign hyperplasia is usually managed with hormone therapy or a minor surgical procedure to remove excess tissue. For pre-cancerous hyperplasia, treatments may include a hysterectomy (removal of the uterus), oophorectomy (removal of the ovaries), or nonsurgical options like hormone therapy.

Treatment for Endometrial Cancer

If you have signs of endometrial cancer, you and your healthcare provider may consider a few treatment options. Your specific treatment plan will likely depend on the tumor’s growth rate, your age, your family and personal medical history, and your preferences. Treatments include:

• Surgery: Removes the tumor and any other abnormal tissue
• Radiation therapy: Uses high-energy X-rays to kill cancer cells, often in combination with other forms of treatment
• Chemotherapy: A drug treatment that uses oral or intravenous (injected into the veins) medication to kill cancer cells and other abnormal tissue
• Hormone therapy: Synthetic hormones help block certain hormones that contribute to the growth of abnormal or cancerous cells and tissue
• Targeted therapy: A newer form of chemotherapy in which the medication is formulated specifically to target abnormal cells, leaving most of your healthy cells intact

Menopause and the accompanying hormonal changes are a natural part of life. Because of that, it might not always be possible to prevent the hormone-related causes of postmenopausal bleeding. However, there are some things you can do to prevent your risk of bleeding after menopause.

For instance, you can help prevent vaginal atrophy by avoiding any items that could further lead to dryness and irritation, including soap, laundry detergent, lotion, and douches. Smoking, tampons, and condoms may also cause or worsen vaginal dryness, so you can avoid those if possible.

You can also prevent endometrial hyperplasia by taking progestin or progesterone if you take estrogen. Losing excess weight can also help.

Excess weight loss and physical activity can also lower your risk of endometrial cancer.

Bleeding after menopause is referred to as postmenopausal bleeding. Any amount of bleeding after your menstrual cycle has permanently stopped is considered abnormal and should be checked out.

Vaginal atrophy is responsible for most cases of postmenopausal bleeding and is mostly harmless and easily treatable. Still, bleeding after menopause should always be evaluated to rule out other potential underlying causes, like endometrial hyperplasia or cancer.