Vaginal bleeding can come as a surprise for women who are years past menopause. Whether it’s light spotting, brown discharge, or heavier bleeding, any kind of bleeding that occurs after menopause is known as postmenopausal bleeding. It’s a form of abnormal bleeding that should always be evaluated by a doctor, even if it’s only a one-time occurrence.(1)
While the initial sight of blood can be concerning, most cases of postmenopausal bleeding are benign. However, there are cases where it may be a sign of a more serious condition. That’s why it’s important that women continue to monitor their vaginal health beyond their reproductive years and promptly contact a healthcare provider at the first sign of anything unusual.
What is postmenopausal bleeding?
Postmenopausal bleeding is any vaginal bleeding that occurs after a woman has reached menopause. Menopause is the point at which a woman has gone 12 consecutive months without a menstrual period. Any bleeding that occurs after this one-year milestone, regardless of the amount or frequency, is defined as postmenopausal bleeding.(2)
The most common form is abnormal uterine bleeding, although the vulva, cervix, urethra, and rectum can also be sources of bleeding. Bleeding after menopause affects around 10% of women and is the reason for approximately 66% of gynecological office visits among postmenopausal women.(2)
Postmenopausal bleeding is different from the irregular bleeding that occurs during perimenopause. Fluctuating hormone levels during perimenopause cause menstrual cycles to become more irregular until they eventually stop completely. While hormonal changes are responsible for irregular bleeding during perimenopause, postmenopausal bleeding has different causes.
Why You Should See a Doctor for Bleeding After Menopause
Instead of waiting to see if the bleeding stops on its own, it’s critical to see a doctor for a comprehensive medical evaluation to determine the cause of postmenopausal bleeding. Postmenopausal bleeding isn’t normal, and while most cases are not cause for concern, it can sometimes be an early sign of endometrial cancer. By having a thorough understanding of the different causes of postmenopausal bleeding, women can be proactive in managing their health and promptly schedule a doctor visit.
Common Causes of Postmenopausal Bleeding
Causes of postmenopausal bleeding can include medication use, certain gynecological conditions, or structural changes in the lower reproductive tract that naturally occur during menopause.
Endometrial and Vaginal Atrophy (Thinning of Tissue)
Sixty percent of postmenopausal bleeding cases are caused by vaginal or endometrial atrophy, making it the most common cause.(2) Atrophy refers to the thinning of body tissues. As hormone levels decline during the menopausal transition, the tissues lining the walls of the vagina and endometrium become thinner and drier. Without enough lubrication, these tissues can become inflamed from friction, which can lead to bleeding or spotting, particularly after sex.
Prescription Medications
Some prescription medications can cause bleeding after menopause, including blood thinners like warfarin and breast cancer treatment drugs like tamoxifen. Certain dietary supplements, such as those containing soy or hops, can have estrogen-like effects on the body, which may also increase the risk of postmenopausal bleeding in some women.(2)(3)
Endometrial Polyps
Endometrial polyps are abnormal growths that develop on the uterine lining. They are sensitive to estrogen and are made up of blood vessels, connective tissue, and glands. Endometrial polyps are responsible for approximately 30% of postmenopausal bleeding cases.(2)(4)
While it’s not fully understood what causes polyps, abnormal uterine bleeding is the most common symptom. The reason endometrial polyps may cause bleeding is believed to be due to a buildup of blood and fluid within the polyp tissue. This can reduce blood flow in the veins and lead to tissue breakdown and bleeding.(4)
Endometrial polyps are typically benign, with only about 1% being cancerous. Although rare, malignancy is more common in postmenopausal women.(2)
Uterine Fibroids
Uterine fibroids are benign, hormone-sensitive tumors that grow on or inside the uterus. They contain smooth muscle cells and connective tissue. A common symptom is abnormal uterine bleeding, which may occur because fibroids place added pressure on the veins. Fibroids can also alter the network of blood vessels in the uterine lining, leading to the formation of new blood vessels. These new blood vessels are often fragile and more prone to bleeding.(5)(6)
Fibroid growths tend to shrink after menopause, and symptoms typically improve. However, they can still persist or cause symptoms in some postmenopausal women.(5)
Endometrial Hyperplasia (Thickening of the Uterine Lining)
Endometrial hyperplasia occurs when the tissue lining the inside of the uterus becomes thicker than normal. One of the most common symptoms of this condition is abnormal uterine bleeding, including postmenopausal bleeding.(7)(8)
It’s caused by an imbalance between estrogen and progesterone levels. Estrogen stimulates the growth of endometrial tissue, but when there isn’t enough progesterone to counteract its effects, the tissue becomes more fragile and sheds irregularly, causing abnormal uterine bleeding.(8)(9)
Women who reach menopause at age 55 or older (late menopause) may be at an increased risk of endometrial hyperplasia. Postmenopausal women with obesity may also be more prone to the condition. As the body continues to produce estrogen in adipose tissue (body fat), the decline in progesterone production after menopause can create an imbalance between the two hormones.(8)
Although rare, it’s possible for benign endometrial hyperplasia to progress into endometrial cancer.(8) Taking action and reaching out to a doctor early on can help ease concerns about malignancy and ensure that treatment is started promptly if needed.
Gynecological Cancers
Endometrial cancer is the most common gynecological cancer associated with postmenopausal bleeding. Cervical and ovarian cancers can also cause bleeding after menopause.(10)
As the cancer progresses, the tumor triggers an increase in blood vessel production to enhance its supply of oxygen and nutrients. Similar to uterine fibroids, these new blood vessels tend to be more fragile, increasing the likelihood of bleeding.(11)
Bleeding While on Hormone Replacement Therapy (HRT)
Bleeding that occurs while on hormone replacement therapy (HRT) is called breakthrough bleeding. It’s more common among women who start HRT less than one year after reaching menopause.(12)
Between 40% and 60% of women using continuous combined HRT experience breakthrough bleeding within the first six months.(13)(14)(15) It usually improves over the first few months of treatment. However, it’s still important to report any breakthrough bleeding to a healthcare provider. Bleeding that lasts for more than three to six months will need to be assessed to determine if it may be related to a health condition.(16)
How Doctors Diagnose the Cause of Bleeding
A doctor may use several methods to diagnose the cause of bleeding after menopause, including physical exams, imaging tests, and medical procedures.
Physical/Pelvic Exams
Physical pelvic exams are an important part of diagnosing the cause of postmenopausal bleeding. The initial consultation typically includes a detailed medical history, including a patient’s menstrual history, and may also involve blood tests. Pelvic exams help identify cervical lesions, polyps, uterine fibroids, or signs of endometrial cancer.(12)
Transvaginal Ultrasound
A transvaginal ultrasound is a diagnostic imaging tool that allows physicians to see the uterus, ovaries, and other reproductive organs. The American College of Obstetricians and Gynecologists (ACOG) recommends it as a first-line test for evaluating postmenopausal bleeding.(17)(18)
The procedure involves inserting a thin tube into the vagina, where the probe emits sound waves. A sonogram image is formed as the instrument records the echoes of the sound waves bouncing off the internal organs. A transvaginal ultrasound can help detect fibroids, polyps, or changes in endometrial thickness.(17)(19)
Endometrial Biopsy
An endometrial biopsy involves extracting a small tissue sample from the lining of the uterus using a flexible instrument with a suction device. This outpatient procedure is used to investigate abnormal bleeding or spotting and is crucial for detecting conditions like endometrial hyperplasia or uterine cancer.(20)
Hysteroscopy
A hysteroscopy procedure involves the insertion of a hysteroscope — a thin, telescope-like device — into the vagina to view the inside of the uterus. There are two types of hysteroscopy: diagnostic and operative. A diagnostic hysteroscopy is used to assess abnormal uterine bleeding, while an operative hysteroscopy is used to remove polyps or other growths.(21)
Treatment Options Based on Your Diagnosis
Treatment options for postmenopausal bleeding depend on the underlying cause. Bleeding related to vaginal or endometrial atrophy may not require treatment. But bleeding associated with fibroids, polyps, endometrial hyperplasia, or gynecological cancers may require medication or surgical intervention.
Vaginal Estrogen Cream
Vaginal estrogen cream is a topical, localized HRT treatment that can be prescribed for women experiencing postmenopausal bleeding caused by vaginal atrophy. The medication works by enhancing blood flow, increasing lubrication, lowering vaginal pH, and thickening the outer layer of cells lining the vaginal walls.(1)(22)
Adjusting HRT Treatment
Breakthrough bleeding can be managed by changing the dose or form of HRT treatment. A study published in Climacteric found that breakthrough bleeding tends to be less common with oral HRT than with transdermal HRT.(23)
Medical or Surgical Treatment of Endometrial Polyps or Uterine Fibroids
Endometrial polyps and uterine fibroids can be surgically removed by a specialist. Uterine fibroids may also be treated with medications, such as aromatase inhibitors or selective estrogen receptor modulators. Aromatase inhibitors lower estrogen levels in the body while selective estrogen receptor modulators block estrogen activity.(1)(2)
Dilation and Curettage
Dilation and curettage (D&C) involves opening the cervix and using an instrument to extract tissue from the uterine lining. In some cases, D&C may be used to treat abnormal uterine bleeding if it doesn’t improve with other treatment methods. However, D&C is more commonly performed as a diagnostic procedure.(24)
Hysterectomy
A total hysterectomy may be recommended in specific cases. The surgery involves the complete removal of the uterus. It’s used to treat gynecological cancers and uterine fibroids, among other health conditions. In addition to a hysterectomy, treatment for gynecological cancers may also include chemotherapy.(1)(25)
Ready to get answers?
Any bleeding that occurs after menopause is not normal and should always be evaluated by a doctor. Understanding the different causes of postmenopausal bleeding can give women the confidence to seek help sooner rather than later. If you’re worried about your symptoms, Winona’s board-certified physicians can guide you to the right care. Start your free consultation today and get answers from a knowledgeable Winona doctor.