Bleeding after menopause

Summary

This article has a single message: any bleeding 12 months or more after your last period, even a single episode of spotting, should be assessed by a doctor. In the great majority of cases the cause is benign: thinning of the vagina or the lining of the womb, a polyp, bleeding related to HRT. But in roughly one woman in ten the cause is cancer of the womb — and that cancer is highly treatable when caught at an early stage. Bleeding is usually the first and only sign. The assessment is simple, quick and usually painless: an ultrasound and, if needed, a sample from the lining of the womb.

What is happening?

After menopause the lining of the womb thins and does not normally bleed. Bleeding happens for these reasons:

• Vaginal or endometrial atrophy (thinning): The commonest cause. Thinned tissue is easily irritated and bleeds; it can be treated (see the separate article on GSM).

• Polyps: Benign growths on the lining of the womb or the cervix; usually removed with a simple procedure.

• Bleeding related to HRT: In a cyclical regimen the expected withdrawal bleed is normal. In a continuous combined regimen spotting can occur in the first 6 months; bleeding that continues beyond 6 months, or starts later, is investigated.

• Endometrial hyperplasia: Excessive thickening of the lining; some types are precancerous and are treated.

• Endometrial (womb) cancer: Found in about 9% of cases of postmenopausal bleeding. Obesity, diabetes, never having given birth, late menopause, unopposed estrogen use and tamoxifen increase the risk.

• Other causes: Cervical lesions, bleeding from the urinary tract or bowel mistaken for vaginal bleeding, and certain medicines (blood thinners).

What do we know?

• The cancer rate is not negligible: In a meta-analysis covering 129 studies, endometrial cancer was found in about 9% of women with postmenopausal bleeding; conversely, in more than 90% of women with endometrial cancer the first symptom was postmenopausal bleeding ². In other words, bleeding is almost always an opportunity to catch the disease early.

• The first step is a transvaginal ultrasound: ACOG accepts measuring the thickness of the lining of the womb by ultrasound as the first assessment; if the thickness is 4 mm or less the likelihood of cancer is very low, and in a woman not taking HRT with a single episode of bleeding a biopsy may not be needed. If the thickness is above 4 mm, if it cannot be measured, or if the bleeding recurs, a sample is taken from the lining ¹.

• The biopsy is usually done in the office: Taking a sample from the lining of the womb with a fine cannula is a procedure that takes a few minutes and usually needs no anesthetic; where it is inconclusive, a hysteroscopy (viewing the inside of the womb with a camera) is planned ¹.

• Referral is fast: In the UK, postmenopausal bleeding over the age of 55 is a symptom requiring specialist assessment within two weeks for suspected cancer; the same pathway is considered under 55 ³.

• Investigation is needed in HRT users too: Guidelines recommend assessing bleeding that falls outside the expected pattern, is prolonged or recurs, even where it is thought to be HRT-related; HRT should be recorded not as an "explanation" for the bleeding but as information your doctor will take into account after it ⁴.

What does this give you?

• Don't wait, but don't panic either: In nine women out of ten the cause is benign. For the tenth, coming forward early saves lives. In both cases the thing to do is the same: make an appointment.

• Record it: The date of the bleeding, the amount (spotting or like a period), how long it lasted, whether it happened after sex, and your regimen if you are taking HRT. You can flag bleeding after menopause in Lumia; it records this, it does not interpret it.

• Try to identify where it came from: If you are not sure whether the blood came from your urine, your stool or your vagina, tell your doctor; it changes the direction of the assessment.

• Even if it is "just dryness": Bleeding due to atrophy is a treatable problem; once it is diagnosed, vaginal estrogen and moisturizers prevent these recurrences.

• Know the risk factors: If you have obesity, diabetes, are taking tamoxifen, or have a family history of womb or bowel cancer, your doctor will plan the assessment accordingly.

Sources

1. ACOG Committee Opinion No. 734: The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. Obstet Gynecol. 2018;131(5):e124-e129.
2. Clarke MA, et al. Association of endometrial cancer risk with postmenopausal bleeding in women: systematic review and meta-analysis. JAMA Intern Med. 2018;178(9):1210-1222.
3. NICE. Suspected cancer: recognition and referral (NG12). 2015; updated 2023.
4. The Menopause Society. The 2022 Hormone Therapy Position Statement. Menopause. 2022;29(7):767-794.

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