Postmenopausal bleeding, also called postmenopausal bleeding, is any vaginal bleeding that occurs after you have stopped having a menstrual cycle for 12 months in a row. Bleeding can be of varying intensity, from light spotting to heavy flow.
Although postmenopausal bleeding is somewhat common—about 10% of people report vaginal bleeding after menopause—it is not normal and may be a sign of underlying health problems. It is important to consult a healthcare professional as soon as possible if you have postmenopausal bleeding.
Several medical conditions can cause postmenopausal bleeding, from physical tears in the walls of the vagina to cancer. Regardless of the cause, vaginal bleeding after menopause is always something to take seriously.
Vaginal atrophy
About 60% of vaginal bleeding after menopause is caused by vaginal atrophy, a condition caused by declining levels of the female reproductive hormone estrogen during and after menopause. With vaginal atrophy, the tissue in the walls of the vagina becomes thinner, drier and less elastic. This thinning can lead to less vaginal bleeding or spotting, especially after penetrative sex.
Endometrial atrophy
Endometrial atrophy occurs when the lining of the uterus (endometrium) thins due to decreased estrogen levels in your body. Over time, the lining can become too thin, which can cause bleeding.
Polyps and fibroids
Polyps and fibroids are non-cancerous growths. They are usually harmless, although they can cause a range of symptoms, including vaginal bleeding.
Polyps cause about 30% of postmenopausal bleeding. Endometrial polyps, or uterine polyps, are growths that form in the lining of the uterus. 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 thickening of the lining of the uterus. Both situations can cause vaginal bleeding. However, fibroids usually shrink and cause no symptoms after menopause. So more often than not the polyps would be the cause of the bleeding and not the fibroids.
Endometrial hyperplasia
Endometrial hyperplasia refers to the thickening of the lining of the uterus. Weight gain 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 (non-cancerous) or precancerous.
Abnormal bleeding, such as bleeding in postmenopausal women, is the most common symptom of endometrial hyperplasia.
Endometrial cancer
Endometrial cancer is a cancer that affects the endometrium (lining of the uterus). About 90% of people diagnosed with endometrial cancer report postmenopausal bleeding as the first symptom that led to their diagnosis. Bleeding can vary in flow and can even be spotty.
In addition to abnormal bleeding, you may experience lower abdominal pain or pelvic cramps if you have endometrial cancer.
Since you no longer have a menstrual cycle, any bleeding after menopause is abnormal bleeding. It is important to see a doctor at the first sign of postmenopausal bleeding. The sooner your doctor diagnoses the cause, the more likely the outcome will be favorable, regardless of the underlying condition.
When you visit your healthcare provider, they may perform or order various tests to help them make a diagnosis. These tests may include a biopsy, ultrasound, or other lab tests. In addition to diagnostic tests, you can expect your doctor to ask questions about your personal and family medical history.
Physical exam
Your doctor will likely perform a physical exam during the diagnostic process, including a pelvic exam.
During a pelvic exam, your doctor 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 doctor finds signs of irritation or inflammation, the bleeding may be related to atrophy.
Your doctor will also likely feel a mass or growth during a pelvic exam.
Endometrial biopsy
During a pelvic exam, your doctor 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 biopsy the first-line test for postmenopausal bleeding in people at high risk for cancer.
Taking a tissue sample helps your doctor detect abnormalities, including cancer cells.
Transvaginal ultrasound
Transvaginal ultrasound is another first-line diagnostic tool, especially if your medical and family history puts you at low risk for cancer. Providers can also use this ultrasound to confirm the results of your biopsy by taking a closer look at your uterus. During the imaging test, your doctor will look at the thickness of the lining of the uterus.
If the lining is thicker or shows signs of polyps or fibroids, further testing, such as a hysteroscopy (a thin telescope inserted into the uterus through the vagina and cervix), may be needed for a more detailed examination.
If the ultrasound does not give clear results or does not show the cause of the bleeding, your doctor may recommend other imaging tests, such as magnetic resonance imaging (MRI), to get a detailed view of your uterus.
Laboratory tests
Additional lab tests can help your doctor diagnose postmenopausal bleeding. This may include different types of blood tests.
Your healthcare provider may want to do a Pap test. While Pap smears cannot diagnose postmenopausal bleeding, they can detect associated abnormalities, such as cervical infections or cancer, that may be contributing to the bleeding.
Treatment options may 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 reduce symptoms.
If polyps or fibroids are causing bleeding, the usual treatment plan is surgical excision, where a surgeon removes the growths.
Treatment for endometrial hyperplasia varies. Benign hyperplasia is usually treated with hormone therapy or minor surgery to remove excess tissue. For precancerous hyperplasia, treatments may include hysterectomy (removal of the uterus), oophorectomy (removal of the ovaries), or non-surgical options such as hormone therapy.
Treatment of endometrial cancer
If you have signs of endometrial cancer, you and your healthcare provider may consider several treatment options. Your specific treatment plan will likely depend on the growth rate of the tumor, your age, your family and personal medical history, and your preferences. Treatments include:
- Surgery: It removes the tumor and any other abnormal tissue
- Radiation therapy: It uses high-energy X-rays to kill cancer cells, often in combination with other forms of treatment
- chemotherapy: Drug treatment that uses oral or intravenous (injected into a vein) drugs to kill cancer cells and other abnormal tissues
- Hormone therapy: Synthetic hormones help block certain hormones that contribute to the growth of abnormal or cancerous cells and tissues
- Targeted therapy: A newer form of chemotherapy in which the drug is formulated specifically to target abnormal cells, leaving most of your healthy cells intact
Menopause and accompanying hormonal changes are a natural part of life. Therefore, it may not always be possible to prevent hormone-related causes of postmenopausal bleeding. However, there are some things you can do to prevent the risk of bleeding after menopause.
For example, you can help prevent vaginal atrophy by avoiding any things that could further cause dryness and irritation, including soap, laundry detergent, lotion, and douching. Smoking, tampons and condoms can also cause or worsen vaginal dryness, so avoid them if possible.
You can also prevent endometrial hyperplasia by taking progestin or progesterone if you are taking estrogen. Losing excess weight can also help.
Excessive weight loss and physical activity can also reduce the risk of endometrial cancer.
Bleeding after menopause is called postmenopausal bleeding. Any amount of bleeding after your menstrual cycle has stopped permanently is considered abnormal and should be checked.
Vaginal atrophy is responsible for most cases of postmenopausal bleeding and is generally harmless and easily treated. However, postmenopausal bleeding should always be evaluated to rule out other potential underlying causes, such as endometrial hyperplasia or cancer.