Causes and Risk Factors of Light Spotting After Menopause

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Postmenopausal spotting is light bleeding that occurs in a person with a uterus after they have undergone menopause. Once you have gone 12 months without a menstrual period, you are considered to be in menopause.

Light postmenopausal bleeding may be caused by benign conditions such as:

Because abnormal vaginal bleeding can also be a symptom of endometrial cancer, you should get any abnormal bleeding checked out by a doctor—even if it’s only spotting.

If you're postmenopausal and experiencing vaginal bleeding, keep a note of any other symptoms that may help your doctor pinpoint the cause. While most of the causes of bleeding are of no concern, there are times when spotting could be a sign of a more serious problem.

Menopausal patient consulting with doctor

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How Common Is Postmenopausal Vaginal Bleeding?

Vaginal bleeding occurs in approximately 4% to 11% of people who are postmenopausal and accounts for 5% of gynecology office visits.

Common Causes

Postmenopausal bleeding can be due to a number of causes. Examples of some of the most common causes include:

Vaginal and Vulvar Atrophy

Postmenopausal atrophic vaginitis, or vaginal and vulvar atrophy (VVA), is the thinning of the walls of the vagina caused by decreased estrogen levels during menopause. As a result, the lining of the vagina may be more likely to bleed.

Vaginal and vulvar atrophy is caused by cellular changes during menopause. Changes in estrogen levels also cause a decrease in blood flow to the vaginal area, which further contributes to vaginal dryness and discomfort. Spotting during and after intercourse is a common symptom of VVA.

At least half of those who enter menopause have signs and symptoms of VVA, but only 20% to 25% seek medical attention from their doctor.

Polyps

Any bodily surface that is lined with a mucous membrane that is rich in blood vessels can produce a growth called a polyp. Cervical polyps are finger-like growths on the lower part of the uterus that connects with the vagina. When polyps grow inside the cervical canal, you may experience bleeding when you have sex.

In the general population, the estimated prevalence of cervical polyps is between 2% and 5%. Although cervical polyps are commonly benign, malignant polyps can present in 0.2% to 1.5% of the cases. Malignant polyps are more likely to be seen in postmenopausal patients.

Endometrial Hyperplasia

This condition causes the uterine lining to become thicker, giving rise to heavy or irregular bleeding. The cause of this condition is most commonly excess estrogen without the hormone progesterone to offset it.

Endometrial hyperplasia usually occurs after menopause, when ovulation stops and progesterone is no longer made. The most common sign of hyperplasia is abnormal uterine bleeding.

There are two classifications of endometrial hyperplasia:

  • Hyperplasia without atypia
  • Atypical hyperplasia

Endometrial hyperplasia is not endometrial cancer, but if atypia is present it is considered a precancerous condition. In fact, in some cases of significant atypical hyperplasia, a very early stage endometrial cancer may already be present.

Endometrial Cancer

Endometrial cancer, the main type of uterine cancer, starts in the cells that make up the endometrium—the lining of the uterus.

The most common symptom of endometrial cancer is abnormal uterine bleeding, either irregular periods, bleeding between periods, or bleeding a year or more after you've gone through menopause.

Like any type of cancer, the earlier it's detected, the better your outcome will likely be. Many cases of endometrial cancer are diagnosed at early stages because the abnormal bleeding prompts people to see their doctors.

An analysis of 40,790 people in 129 studies suggests that postmenopausal bleeding occurs in approximately 90% of those with endometrial cancer; however, only 9% of those with postmenopausal bleeding were diagnosed with endometrial cancer.

Rare Causes of Postmenopausal Spotting

Other potential causes of postmenopausal bleeding include:

  • Infection of the uterine lining, known as endometritis
  • Injury to the vagina from the insertion of foreign objects or sexual trauma
  • Some medications, such as tamoxifen for breast cancer or blood-thinning medications (anticoagulants)
  • Sexually transmitted infections (STIs) such as chlamydia, gonorrhea, and herpes can cause postmenopausal bleeding.
  • Menopausal hormone replacement therapy (some will experience breakthrough bleeding in the first six months of hormone replacement therapy.)
  • In some cases, cancer of the cervix and vagina can also cause postmenopausal spotting.

Genetics

The benign causes of postmenopausal spotting are largely down to natural bodily changes that happen after menopause, and there are no common genetic causes.

However, a gene mutation or genetic disorder may increase your risk of endometrial cancer. One genetic disorder that contributes to a high risk of endometrial cancer is hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome. This condition increases your risk of certain cancers, especially colon cancer, endometrial cancer (your likelihood of developing it is 40% to 60%), and ovarian cancer.

If anyone in your family has HNPCC or if you've been diagnosed with it, talk to your doctor about cancer screenings you should undergo. Being aware of your elevated risk and being proactive about testing can lead to early detection and successful treatment in the event that you develop cancer.

Risk Factors

Risk factors for postmenopausal bleeding often depend upon the underlying cause associated with the bleeding. For endometrial cancer, certain factors can increase a person's risk, but they don't always cause the disease, and some cannot be prevented (such as aging or genetics).

Factors affecting the risk of developing endometrial cancer include:

  • Age: Most cases of endometrial cancer are diagnosed in people who are past menopause and are in their mid-60s.
  • Levels of hormones: The levels of estrogen and progesterone in your body can affect your risk of endometrial cancer. When estrogen is present without enough progesterone, it can cause the endometrium to become too thick (endometrial hyperplasia), which if atypia is present is considered a precancerous condition.
  • Being overweight: Endometrial cancer is twice as common in those who are overweight (BMI 25 to 29.9), and more than three times as common in those who are obese (BMI > 30).
  • Total number of menstrual cycles: Having more menstrual cycles during a lifetime raises your risk of endometrial cancer. Starting menstrual periods before age 12 and/or going through menopause later in life raises the risk.
  • Pregnancy: The hormonal balance shifts toward more progesterone during pregnancy. So having many pregnancies helps protect against endometrial cancer. Those who have never been pregnant have a higher risk, especially if they are also infertile.
  • Diabetes: Endometrial cancer may be about twice as common in people with a uterus who have type 2 diabetes.
  • Family history: Lynch syndrome increases the risk of colon cancer, ovarian cancer, endometrial cancer, and other types of cancer. It is caused by a change or mutation in a gene that is passed down in families.

It's worth noting that many people with these risk factors never develop endometrial cancer.

A Word From Verywell

While it is not uncommon to experience some irregular bleeding before you go through menopause, irregular bleeding before menopause and bleeding after menopause is something that should be investigated.

Although spotting after menopause is usually for benign reasons, you should always consult your doctor if you have postmenopausal bleeding to rule out more serious causes, such as endometrial cancer. If you are in a high-risk category due to your family history, you should be offered regular cancer screenings.

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