Postmenopausal bleeding: why you should get it checked

Any vaginal bleeding that appears after twelve months in a row without a period should be checked, even if it's only light spotting, brown in colour or has happened just once. Most of the time the cause is benign, such as a fragile lining or a polyp. But postmenopausal bleeding is also the most typical warning sign of endometrial cancer (the endometrium is the layer lining the inside of the womb), and the way to rule it out is a gynaecological assessment, not waiting to see if it happens again.

What counts as postmenopausal bleeding?

The menopause is confirmed when twelve months in a row pass without a period. From then on, any loss of blood from the vagina falls into this category:

• Pink or brown spotting on your underwear.
• Traces of blood when you wipe.
• Bleeding similar to a period, even if it doesn't last long.
• Bleeding after sex.

In the years before, during the perimenopause, irregular periods are to be expected. If you're unsure where you are, the menopause page explains how it's confirmed. And if you bleed after a whole year without a period, don't take it as a period coming back: get it checked.

Most common causes

• Thinning of the lining (atrophy). As oestrogen levels fall, the vagina and endometrium become thinner and more fragile, and can bleed with friction or during sex. This is one of the most common causes.
• Polyps of the endometrium or cervix: growths that are nearly always benign and bleed easily.
• Hormone therapy. Some regimens cause expected bleeding and others can cause spotting in the first few months (we look at this further down).
• Endometrial hyperplasia: the endometrium thickens because of excess stimulation by oestrogen. Some forms can develop into cancer if they aren't treated.
• Endometrial cancer and, less often, cancer of the cervix, vagina or vulva.

Sometimes the blood doesn't come from the genital tract but from the urine or the rectum. Telling these apart is part of the examination.

Why it's best not to wait, even if there was only a little

Endometrial cancer usually gives an early warning, precisely with this symptom, and when it's diagnosed at an early stage treatment has better results. That's why any bleeding after the menopause without a clear explanation should be investigated as a priority.

The risk is higher with obesity, diabetes, or treatment with oestrogen without progesterone or with tamoxifen. But having these factors or not doesn't change the recommendation: the bleeding should be checked either way. Nor does it change if it has stopped by itself.

What to note down before your appointment

• The approximate date of your last period.
• When the bleeding started, how long it lasted, how much there was and whether it has happened again.
• Whether it appears after sex or for no apparent reason.
• Whether you notice dryness, itching or pain during sex, because this points towards atrophy.
• All your medication: hormone therapy (type and since when), tamoxifen, anticoagulants or antiplatelet medicines.
• Your latest smear test or HPV test results and any previous ultrasound scan.

How it's investigated: examination and transvaginal ultrasound

The appointment starts with your medical history and a gynaecological examination, which helps to see where the bleeding is coming from: vulva, vagina, cervix or inside the womb. If appropriate, a smear or HPV test is taken, as in a gynaecological check-up.

The key test is a transvaginal ultrasound, done through the vagina, which measures the thickness of the endometrium. It's quick and usually well tolerated. A very thin endometrium, in a first episode, makes cancer very unlikely, and it's often enough to treat the cause and monitor. If you are on hormone therapy, that thickness is interpreted differently depending on your regimen.

If the endometrium is thickened, looks irregular or the bleeding happens again, it usually needs to be investigated further with an endometrial biopsy, which takes a small sample from inside the womb, or with a hysteroscopy, which allows it to be seen from the inside and any polyp to be removed.

If you are on hormone therapy

With menopausal hormone therapy, bleeding is not necessarily a warning sign. On cyclical regimens, where progesterone is taken for only part of the month, bleeding similar to a period is expected on the planned days, and on continuous regimens, with both hormones every day, irregular spotting is common during the first few months. See a doctor if the bleeding appears outside what's expected, if it continues after those first months, if it comes back after a time without bleeding or if it's heavy.

Treatment depending on the cause

It depends on what is found: moisturisers or local oestrogen for atrophy, removal of polyps, adjusting the hormone regimen or treating the hyperplasia. If the investigation points to cancer, a specialist team will usually complete the diagnosis and plan the treatment.

When the cause is atrophy, it's worth knowing that it's a chronic process: as well as treating the episode, it helps to keep up the care, such as regular vaginal moisturisers or lubricant during sex, because if you give them up the dryness comes back. And the fact that the cause was benign the first time doesn't mean you don't need to get checked if the bleeding returns: each new episode is assessed.

When to go to A&E

If the bleeding is heavy, with large clots, or comes with dizziness, paleness, fainting or severe pain, don't book an appointment: go to A&E or call 112.

For everything else, book an appointment in gynaecology when the bleeding appears, without waiting for your next check-up. In most cases the answer is reassuring, and getting checked early is what makes it possible to give it with confidence.