What Is Postmenopausal Bleeding?

Postmenopausal bleeding is bleeding from the reproductive tract that occurs after a person has stopped having menstrual periods and has gone through menopause.

Menopause is defined as going 12 months without a period. It happens to most females in the United States at an average age of 52. Postmenopausal bleeding can stem from anywhere in the reproductive tract, including the uterus, vagina, and cervix.

Postmenopausal bleeding is not normal, but it does happen. Research indicates that up to 10% of postmenopausal women over age 55 experience bleeding after their periods end.

Postmenopausal Bleeding Symptoms

Postmenopausal bleeding is most likely to occur in people who are in their first year after menopause. But regardless of when it occurs, symptoms can run the gamut. You may experience:

• Light spotting
• Heavy bleeding, like a normal period
• Blood that appears pinkish
• Blood that appears brownish

Most of the time there is no pain associated with postmenopausal bleeding. But depending on its cause, it’s possible that you may also experience:

• Cramping
• Pelvic pain

Get checked out by a healthcare professional even if the bleeding is very light or a one-time thing. Some causes of postmenopausal bleeding can be serious, so it’s important to get prompt medical attention.

Causes

Most cases of postmenopausal bleeding have benign, or nonserious, causes. These include:

Atrophy

Estrogen helps keep the walls of the vagina and uterus elastic and supple. In menopause and afterward, your estrogen is declining or at very low levels. The blood vessels that line those walls can become thin and dry, making them prone to breaking. This can happen due to the friction of sex, and sometimes just spontaneously.

In one study looking at bleeding in postmenopausal women, 61% were diagnosed with an atrophic endometrium (a uterine lining that’s smaller and thinner than seen in premenopausal females).

Endometrial Cancer

Roughly 9% of people who have bleeding after menopause are diagnosed with endometrial cancer. It is the most common gynecologic cancer in the United States.

Endometrial Hyperplasia

Progesterone also helps the uterine lining change in preparation to receive a fertilized egg. The drop in progesterone is what triggers the uterine lining to shed (menstruation). If this process isn't occurring due to lack of ovulation, this can cause the uterine lining not to shed and to continue to thicken and become endometrial hyperplasia.

Using estrogen-only hormonal replacement therapy (which may help minimize some menopausal symptoms, such as hot flashes) after menopause can raise the risk of endometrial hyperplasia.

Experts now recommend that people with a uterus who take estrogen after menopause temper its effects with a progestin, a synthetic form of progesterone.

Uterine Polyps

Thirty percent of postmenopausal women complaining of uterine bleeding have uterine (also called endometrial) polyps.

Uterine polyps are an overgrowth of endometrial glands, tissue, and blood vessels. They’re usually noncancerous and are common both before and after menopause.

Uterine Fibroids

Uterine fibroids are noncancerous tumors that often cause heavy bleeding. Up to 80% of people with a uterus will have one or more uterine fibroids at some point in their lives.

Because fibroids are fed by estrogen and progesterone, they’re most likely to occur before menopause. But some people can experience them after menopause. One study found that women ages 50 to 59 had the second-highest incidence of uterine fibroids.

Diagnosis

Viewing inside the vagina and uterus, and in some cases taking a tissue sample, are key to determining the cause of postmenopausal bleeding. To do that, you may need to undergo a variety of tests. Some of these include:

• Pelvic exam: A small plastic device called a speculum will separate the walls of the vagina so your doctor can examine the vagina and the cervix, which connects the vagina to the uterus.
• Transvaginal ultrasound: A probe (called a transducer) is inserted into the vagina. Soundwaves from the transducer pass through the skin, creating echoes and electrical signals that are converted into images. This is often used to check the thickness of the lining of the uterus, which can help your doctor assess your risk of endometrial cancer 
• Hysteroscopy: This involves inserting a thin, lighted tube with a camera on the end into the vagina to view the vagina, cervix, and uterus.
• Sonohysterography: A thin tube inserts fluid into the uterus so soundwaves can capture more detailed images of the uterus.
• Endometrial biopsy: Your doctor will use a thin suction device to remove some endometrial tissue that is sent to a lab for analysis. The procedure is typically done in a doctor’s office without anesthesia.
• Dilation and curettage (D&C): This is often done as outpatient surgery. The endometrium is scraped to remove a sample that is then sent to a lab for testing.

Treatment

Treatment for postmenopausal bleeding depends on its cause:

• Atrophy: If you have a naturally occurring thinning of your uterine or vaginal lining, your healthcare professional may recommend a vaginal estrogen cream or a vaginal moisturizer, as well as using a lubricant during sex. In some cases, you may not need any treatment at all, as the bleeding often goes away on its own.
• Polyps or fibroids: You may need surgery to remove the growths. This can often be done as a minimally invasive procedure, using a thin, lighted instrument called a laparoscope. 
• Endometrial hyperplasia: Some people with endometrial hyperplasia can be helped by taking the hormone progestin. Surgery to remove the uterus (called a hysterectomy) may be recommended for some. 
• Cancer: If you’re diagnosed with gynecologic cancer, you may need surgery, chemotherapy, and/or radiation.

Summary

Bleeding after menopause may be due to atrophy, endometrial hyperplasia, uterine polyps or fibroids, or gynecologic cancer. It should always be reported to your healthcare professional so they can diagnose the cause. The treatment may require medication or surgery.

A Word From Verywell

Many people experience bleeding after menopause. In most cases, the cause isn’t serious. Still, it’s important to check in with your healthcare professional whenever you experience postmenopausal bleeding.

Because vaginal bleeding can be an early sign of endometrial cancer, your doctor will definitely want to check for that. Once the cause of your bleeding is determined, your doctor can advise you about treatment options and the next steps.