Postmenopausal Bleeding

Medically Reviewed by Traci C. Johnson, MD on March 09, 2024
4 min read

If you’ve gone through menopause, you shouldn’t have any menstrual bleeding. Menopause means you haven’t had a period in at least one year.

If you have any bleeding -- even if it’s only spotting -- you should see a doctor. They’ll want to rule out serious causes, like cancer.

A number of conditions may lead to postmenopausal bleeding:

Polyps: These tissue growths show up inside your uterus or cervical canal, or on your cervix. They’re usually not cancer, but they can cause spotting, heavy bleeding, or bleeding after sex.

Endometrial atrophy (thinning of the uterine lining): The endometrium is the tissue that lines your uterus. It responds to hormones like estrogen and progesterone. Low hormone levels after menopause can cause it to get too thin. This may trigger bleeding.

Endometrial hyperplasia (thickening of the uterine lining): After menopause, you may have too much estrogen and too little progesterone. As a result, the endometrium gets thicker and can bleed. Sometimes cells in the endometrium can become abnormal. This could lead to cancer, so get it treated as soon as possible.

Vaginal atrophy (thinning of vaginal tissue): Estrogen helps to keep this tissue healthy. After menopause, low estrogen levels can cause your vaginal walls to become thin, dry, and inflamed. That often leads to bleeding after sex.

Cancer: Bleeding is the most common symptom of endometrial or uterine cancer after menopause. It can also signal vaginal or cervical cancer.

Sexually transmitted diseases: Some, like chlamydia and gonorrhea, may cause spotting and bleeding after sex. Herpes sores can also bleed.

Medications: Bleeding is often a side effect of certain drugs, like hormone therapy, tamoxifen, and blood thinners.

To find the cause of your bleeding, the doctor will do a physical exam and review your medical history. You may need one or more of the following tests:

Transvaginal ultrasound: This image helps your doctor check for growths and look at the thickness of your endometrium. They’ll place a small probe into your vagina. It sends off sound waves to create a picture of the inside of your body.

Endometrial biopsy: The doctor uses a thin tube to take a small sample of the tissue that lines your uterus. They’ll send it to a lab where scientists will look for anything unusual, like an infection or cancerous cells.

Sonohysterography: Your doctor may use this test to measure the size of a polyp. They’ll put a saltwater solution inside your uterus to create a clearer ultrasound image.

Hysteroscopy: When the doctor needs to look inside your uterus, they’ll use a hysteroscope. This thin, lighted tube has a camera on one end.

D&C (dilation and curettage): During this procedure, the doctor dilates your cervix. They use a thin tool to scrape or suck a sample of the uterus lining. They send this to a lab that will check for polyps, cancer, or a thickening of the uterine lining (endometrial hyperplasia).

Ultrasound and biopsy are usually done in your doctor’s office. Hysteroscopy and D&C require anesthesia on one part of or your whole body. You’ll either go to a hospital or an outpatient surgical center.

That depends on what’s causing the bleeding.

Estrogen therapy: This hormone is used to treat vaginal and endometrial atrophy. Your doctor may prescribe it in one of the following forms:

  • Pills: You’ll take them by mouth.
  • Vaginal cream: You’ll use an applicator to get it inside your body.
  • Vaginal ring: You or your doctor can put it in place. It releases a steady dose of estrogen for about 3 months.
  • Vaginal tablet: You’ll insert it using an applicator. You may need to do it daily, or a few times a week.

Progestin therapy: This lab-made version of progesterone is used to treat endometrial hyperplasia. Your doctor may prescribe it in a pill or shot, a vaginal cream, or intrauterine device.

Hysteroscopy: This procedure can remove polyps. Doctors also use it to remove thickened parts of the uterine lining caused by endometrial hyperplasia. They’ll insert a hysteroscope into your vagina and pass tiny surgical tools through the tube.

D&C (dilation and curettage): In this surgery, the doctor opens your cervix. (You may hear them say they are going to dilate it). They use a thin tool to remove polyps or thickened areas of the uterine lining caused by endometrial hyperplasia.

Hysterectomy: This surgery removes part or all of your uterus. It’s a treatment for endometrial or cervical cancer. Some people with a precancerous form of endometrial hyperplasia may also need it. In some cases, the doctor may also take out your ovaries, fallopian tubes, or nearby lymph nodes.

Radiation, chemotherapy, and hormone therapy: You may need more cancer treatment after surgery. Your doctor will prescribe one based on what type of cancer you have and what stage it’s in.

Medications: Your doctor can prescribe drugs like antibiotics for sexually transmitted diseases. They can also treat cervical or uterine infections.

The years before menopause are called perimenopause. During this time, your hormones shift. Your period may be heavier or lighter than usual. You may also have spotting. That’s normal. But if your bleeding is heavy or lasts longer than usual, talk to your doctor. You should also get checked out if you bleed after sex.