Postmenopausal bleeding

Postmenopausal bleeding means bleeding from the vagina after you have gone at least 12 months without a menstrual period. It may be light spotting, blood-streaked discharge, or bleeding that resembles a period.

Bleeding after menopause is often caused by non-cancerous changes, such as thinning of vaginal or womb tissues. However, it can sometimes be a sign of abnormal cells or cancer of the womb lining. For this reason, even a small amount of bleeding should be checked.

Arrange an appointment even if the bleeding happened only once, stopped quickly, or did not cause pain. This advice also applies if you are using hormone replacement therapy, known as HRT.

Blood seen on underwear or toilet paper does not always come from the vagina. It may come from the urinary tract or rectum. A medical assessment can help identify the source.

Postmenopausal bleeding can appear as:

• A few spots of red, pink, or brown blood
• Pink or blood-streaked vaginal discharge
• Bleeding similar to a menstrual period
• Bleeding after sex
• Bleeding that stops and later returns

You may have no other symptoms. Some people also notice vaginal dryness, discomfort during sex, pelvic pressure, or lower-abdominal cramping.

Note when the bleeding began, how much there was, and whether it followed sex or occurred with pain. This information can be useful at your appointment.

The most common causes are changes in the vagina or womb that are not cancer.

Thinning vaginal or womb tissues: After menopause, lower estrogen levels can make the lining of the vagina or womb thinner and more fragile. This is called atrophy. The tissues may bleed after sex or without an obvious trigger. Vaginal dryness, burning, or soreness may occur too.

Polyps: These are usually non-cancerous growths arising from the cervix or womb lining. They can cause irregular spotting or bleeding after sex.

Hormone therapy: HRT can cause bleeding, particularly after starting treatment or changing the dose or type. The expected pattern depends on the HRT regimen. New, persistent, or unexpected bleeding still needs medical review.

Less common causes include inflammation or infection of the cervix or womb lining, injury to vaginal tissue, and thickening of the womb lining. Thickening caused by abnormal cell growth is called endometrial hyperplasia. Some forms can develop into cancer if untreated.

Cancer of the womb lining, called endometrial cancer, is an important but less common cause. Cervical, vaginal, ovarian, or vulval cancer may also cause bleeding. Assessment is important because symptoms alone cannot show what is causing it.

Blood-thinning medicines may make bleeding heavier, but they should not be assumed to be the only cause. Do not stop a prescribed medicine unless the clinician responsible for it advises you to do so.

Book a prompt medical appointment for any vaginal bleeding after menopause. You should be assessed even if:

• It happened only once
• There was only a small amount
• You are taking HRT
• You have no pain or other symptoms
• A previous assessment found no serious cause but bleeding has returned

Seek same-day medical advice if the bleeding becomes heavy, such as soaking through a pad in about an hour, or if you are passing large clots.

Seek emergency care if heavy bleeding occurs with fainting, severe dizziness, confusion, marked weakness, chest pain, or difficulty breathing. These symptoms may mean that blood loss is affecting your circulation.

Severe or rapidly worsening pelvic or abdominal pain also needs urgent assessment.

The clinician will ask when your periods stopped, what the bleeding looked like, and whether it has happened more than once. They may ask about HRT, tamoxifen, blood-thinning medicines, previous gynaecological conditions, and your family medical history.

A pelvic examination may be offered. A device called a speculum may be used to gently open the vagina so the vaginal walls and cervix can be seen. Tell the clinician if examinations are painful or worrying; they can discuss ways to make the process more comfortable.

You may have a transvaginal ultrasound. A slim ultrasound probe is placed in the vagina to examine the womb and measure its lining. This scan may also show polyps or other structural changes.

Depending on the findings, a small sample of the womb lining may be taken for testing. This is called an endometrial biopsy. Another test, called hysteroscopy, uses a thin camera passed through the cervix to look inside the womb. A biopsy or polyp removal may be performed at the same time.

Persistent or repeated bleeding may need further investigation even when an earlier ultrasound was reassuring.

Treatment depends on where the blood comes from and what caused it.

Thinning vaginal tissue may be treated with non-hormonal vaginal moisturisers or prescribed vaginal estrogen. Polyps can often be removed during hysteroscopy. Infection or inflammation may require specific medicine after an examination and, when appropriate, testing.

If HRT appears to be contributing, the prescriber may adjust its type, dose, or schedule. Do not change or stop prescribed hormones on your own before seeking advice.

Endometrial hyperplasia may be treated with hormone therapy, monitoring, or surgery, depending on the cell changes found. If cancer is diagnosed, a specialist team will discuss treatment options with you.

While waiting for assessment, use pads or period underwear if needed and keep a simple record of bleeding. Note the colour, amount, clots, pain, and possible triggers. Self-care cannot replace assessment, and there is no home treatment that can reliably identify the cause.

Many causes of postmenopausal bleeding are treatable. Your next steps will depend on the examination, ultrasound, and any tissue test.

If no serious cause is found and the bleeding stops, you may only need routine follow-up. Follow the plan provided by your healthcare team.

Return for medical review if bleeding continues or happens again, even after reassuring test results. A change in the pattern, heavier bleeding, or new pelvic symptoms may require another assessment.

Waiting for tests can feel unsettling. Ask when to expect results, who will contact you, and what to do if the bleeding changes while you wait.

Is light spotting after menopause normal?

It is common for non-cancerous tissue changes to cause spotting, but bleeding after menopause is not treated as a normal menstrual event. Even one small episode should be checked.

Could the blood be from somewhere else?

Yes. Blood from the bladder, urinary opening, rectum, or skin can be mistaken for vaginal bleeding. Tell the clinician about pain when urinating, blood in urine, constipation, haemorrhoids, or rectal bleeding.

Does bleeding while taking HRT need checking?

Bleeding can occur with HRT, especially after treatment begins or changes. Whether it is expected depends on the regimen and timing. Report new, persistent, heavy, or otherwise unexpected bleeding to the HRT prescriber.

Does postmenopausal bleeding mean cancer?

No. There are several possible causes, and many are non-cancerous. However, womb cancer can cause this symptom, so timely assessment is important.

Can a normal ultrasound rule out every cause?

No test rules out every cause in every situation. If bleeding persists or returns, contact your healthcare team even if an earlier scan was reassuring.