Post-Menopausal Bleeding: Spotting After Menopause

Once a woman has gone 12 consecutive months without a menstrual period, she is deemed to have reached menopause. The time after this is considered postmenopause1. Postmenopause, you will no longer have periods, but many women do continue to have menopause symptoms including hot flushes and vaginal dryness.

Therefore, it can be quite unsettling to experience bleeding after menopause. Post-menopausal bleeding occurs in about 10% of women over 552 but is considered unusual and should be checked, even if it only happens once.

Our Menopause Doctor, Liz Andrew says:

“Post menopausal bleeding is a common presentation at the GP surgery and in menopause clinics, especially for women on HRT. Often it’s really nothing to worry about but occasionally it can be a good early indicator of something more serious which can then be investigated and treated. I encourage all women to reach out for support if you experience bleeding after your menopause.”

What is post-menopausal bleeding?

Menstrual bleeding (a period) is a normal part of a woman’s menstrual cycle. How often it occurs varies between individuals, but it’s usually every 21 to 35 days3.

In perimenopause, periods can become irregular, changing in flow, duration and frequency4. Menopause is reached when they stop altogether and while it isn't often formally diagnosed, a woman is considered to have reached menopause once she hasn’t had any periods for a year.

Post-menopause is the stage after this and lasts for the rest of life5. Post-menopausal bleeding is any vaginal bleeding that occurs after menopause.

Is post-menopausal bleeding normal?

Any vaginal bleeding or spotting 12 months or more after your last period is not considered normal and should be taken seriously.

In most instances, it is a sign of a minor health problem, but it can be an early indication of something more serious so should be reviewed with a healthcare professional who will usually investigate the bleeding further with additional tests6.

Symptoms and types of post-menopause bleeding

Any vaginal bleeding after menopause is considered post-menopausal bleeding but women can experience different types of bleeding including:

A small amount of blood
Bleeding that is like a menstrual period
Light pink, brown or red spotting
Heavy bleeding which is bright or dark red
Blood clots that pass with other bleeding
Bleeding after vaginal sex
Pink or brown vaginal discharge
Heavier bleeding than experienced during menstrual periods
Blood on toilet paper after going to the toilet7

Women may experience post-menopausal bleeding on its own, but it can be accompanied by other symptoms such as:

Abdominal pain or cramping
Fever
Chills
Dizziness
Headaches
Pain or discomfort during sex
Unexplained weight loss
Changes in bladder and/or bowel function7

The causes of bleeding after menopause

There are many causes of post-menopausal bleeding, most of which are not serious and easily treatable. Occasionally, bleeding after menopause can be an indication of something more serious.

Causes of vaginal bleeding include:

Hormone replacement therapy (HRT) – changing or stopping HRT can cause vaginal bleeding. When it comes to HRT and cancer risk, it can also slightly increase the risk of some cancers, of which vaginal bleeding can be a symptom. Postmenopausal bleeding on HRT is more common than when not taking HRT and is less likely to be a serious cause, but should be reviewed all the same.
Vaginal atrophy – due to reduced oestrogen, the skin of the vaginal wall can become thin, dry and/or inflamed, making it more prone to breakage and bleeding
Endometrial atrophy – thinning or inflammation of the uterine lining
Polyps – usually benign growths that grow on the cervix or uterine lining
Fibroids – non-cancerous uterine growths
Cervicitis – inflammation of the cervix
Endometrial hyperplasia – excessive thickening of the uterine lining
Endometrial cancer
Cervical cancer
Ovarian cancer
Injury or trauma to the vagina
Bleeding from other organs such as the bladder or rectum
Infections of the cervix or uterus2,7

Does bleeding after menopause mean cancer?

No, bleeding after menopause isn’t always a sign of cancer. In most cases, it is caused by something easy to treat. However, certain cancers can cause post-menopausal bleeding which is why it’s so imperative to get any bleeding checked.

Around 90% of people with uterine cancer experience vaginal bleeding before their diagnosis2. In cases of cervical cancer, bleeding after sex occurs in up to 40% of women and research calculates that in women aged 45-54, this risk of cervical cancer when experiencing post-coital bleeding is 1 in 24008. In women with ovarian cancer, 13% report experiencing abnormal vaginal bleeding9.

Risk factors for post-menopausal bleeding

Any woman can experience post-menopausal vaginal bleeding. However, a woman may be at increased risk of vaginal bleeding if they:

Have a history of uterine or cervical polyps
Have fibroids
Have been prescribed hormone therapy
Take tamoxifen
Experience sexual trauma
Smoke cigarettes
Are impacted by obesity
Have polycystic ovary syndrome (PCOS)
Reach menopause later than average
Have a personal or family history of diabetes, breast cancer, endometrial cancer and/or colon cancer2,7

Diagnosing post-menopausal bleeding

The cause of vaginal bleeding after menopause can usually be determined based on medical history, a physical exam and diagnostic tests. A pelvic exam will look for internal areas of soreness or tenderness or any signs that bleeding has occurred7.

Further investigative testing may include:

Transvaginal ultrasound - provides imaging of the uterus and endometrial thickness to identify abnormalities, such as atrophy, polyps, fibroids, or endometrial hyperplasia.
Direct visualisation of the cervix - to check for visual changes of a cancer or other benign changes of the cervix which might bleed such as ectropion or polyp. Hysteroscopy - Allows direct visual inspection of the uterus to identify and, if necessary, remove abnormalities like polyps or assess signs of cancer.
Endometrial biopsy - Samples of the uterine lining are taken for cellular analysis, aiding in diagnosing endometrial hyperplasia or cancer.
Cervical biopsy – Tissue is taken from the cervix to evaluate abnormalities or lesions.2,7

Treatment for post-menopausal bleeding

Treatment for post-menopausal bleeding depends on what is causing it.

HRT: If post-menopause bleeding is a side effect of HRT, changing the type or dose, or stopping HRT altogether may be recommended.
Vaginal or endometrial atrophy: Low-dose vaginal oestrogen creams, pessaries, or rings, and non-hormonal vaginal moisturisers can restore the thin, fragile vaginal and endometrial tissue, alleviating bleeding and discomfort. Vaginal lubricant can also help if bleeding happens predominantly after sex.
Polyps of fibroids: Polyps can be removed via hysteroscopy, while fibroids may require medication or surgery, depending on size and symptoms.
Infection: Antibiotics can treat most underlying infections, such as bacterial vaginosis or pelvic inflammatory disease, resolving bleeding and inflammation.
Endometrial hyperplasia: Treatment may involve progestin therapy (oral or the IUS (Mirena coil) to thin the uterine lining. Severe cases might require dilation and curettage surgery or hysterectomy.
Cancer: Treatment depends on the type and stage of cancer but may include radiation, chemotherapy, or hormone therapy. In some cases, a hysterectomy, which can include removal of the ovaries and fallopian tubes as well as the uterus, may be necessary. 2,7,10

When to see a doctor about post-menopausal bleeding

While most causes of bleeding after menopause aren’t a major cause for concern, between 10 and 15% of women who experience post-menopausal bleeding may have endometrial cancer7.

For this reason, time is of the essence so that bleeding can be investigated, and diagnosis and treatment can occur swiftly. Women are advised to see a doctor even after just one instance of spotting or bleeding after menopause.

If you've had postmenopausal bleeding, no matter how small or light it was, you should speak to a professional.

At Menopause Care, we have a team of specialists who are here to listen to your concerns, understand your symptoms and review your medical history. We can arrange blood tests, scans and other investigations should they be required and develop a tailored treatment plan to help minimise vaginal bleeding if it’s a result of atrophy or your HRT.

For empathetic and evidence-based support, book a consultation with a menopause doctor.

DisclaimerAt Menopause Care, we ensure that everything you read in our blog is medically reviewed and approved. However, the information provided is not meant to replace professional medical advice, diagnosis, or treatment. It should not be relied upon for specific medical advice.

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