Bleeding after menopause (postmenopausal bleeding)

Menopause 

Menopause is actually one day. It marks the day you have been period-free for over a year (yay? Maybe not). The period before you reach this day is called perimenopause and can last months or even years. After the day of menopause, that period is called postmenopause. 

The average age of menopause is around 51 in the UK¹, with the postmenopausal phase lasting about 20-30 years. You might still experience menopause symptoms in the postmenopausal phase but one thing you should not experience is vaginal bleeding of any sort! 

What is postmenopausal bleeding?

Bleeding after your periods have stopped for over 12 months is called postmenopausal bleeding. This form of bleeding is not normal and accounts for 2 thirds of visits to a gynaecology department². 

A large or even small amount of bleeding after menopause and even bleeding after 10 years of menopause is considered postmenopausal bleeding. 

Postmenopausal bleeding can either be bleeding or spotting, but the presence of blood loss from the vagina should be something that gets assessed by a healthcare professional. 

Causes of postmenopausal bleeding

There are multiple reasons for postmenopausal bleeding and the reason might be simple and easily treatable but it could also indicate something more serious like womb (endometrial) cancer. This is why postmenopausal bleeding should always be checked. 

If they’re picked up early, conditions that cause with postmenopausal bleeding are often treatable, including cancer.

Postmenopausal bleeding after intercourse

Usually, postmenopausal bleeding associated with sex is caused by vaginal dryness. During menopause, the ovaries slowly decline in function, so our oestrogen levels decline. This leads to thinning, drying and inflammation of the vaginal wall. In the medical world, this is referred to as atrophic vaginitis³. You could also experience painful intercourse and painful urination.

This is often treated with either lubricants or vaginal oestrogen creams, gels or pessaries which offers relief and stops bleeding. 

Postmenopausal HRT bleeding

In some cases, hormone replacement therapy (HRT) can cause some bleeding. 

It is common in the first few months of starting HRT to experience irregular bleeding or spotting and this happens in around 40% of users⁴. This should settle after 6 months⁵. If it doesn’t, you need to see your doctor for a referral for a scan to check the thickness of your womb lining. If everything is normal, and your HRT is the cause of postmenopausal bleeding, they will discuss swapping or stopping your HRT altogether⁴. If your womb lining is thickened, you will be referred to the gynaecology department for further tests.

Fibroids bleeding postmenopausal

Fibroids can cause bleeding after menopause. However, as fibroids grow due to oestrogen and oestrogen levels decline after menopause, fibroids tend to shrink during the postmenopausal phase. 

Bleeding after menopause and back pain, along with abdominal pressure, might point towards fibroids. Typically, fibroids are picked up on ultrasound scans. A hysterectomy (surgical removal of the uterus as a whole) might be more readily offered depending on the size, location and symptoms severity of the fibroid, along with your medical history and suitability for surgical procedures. Not all fibroids in menopause meet the criteria for surgery so medication or less invasive procedures can also be used as a treatment.

Endometrial hyperplasia postmenopausal bleeding

Endometrial hyperplasia is not a form of cancer but it can develop into womb cancer over time. It described the thickening of the uterine lining. It is usually caused by high oestrogen levels in the body, which means the lining grows, but may not shed in a period, either because of problems with ovulation (like in polycystic ovary syndrome) or if you are not taking enough progesterone as part of your HRT. These cells keep growing and thicken with the potential to lead to cancer⁶. 

Endometrial hyperplasia is treated with progestogen hormones either as a Mirena coil or tablets. However, if the changes to the lining show an increased cancer risk, your doctor might suggest a hysterectomy instead.

Is bleeding after menopause always cancer?

90% of postmenopausal bleeding is not caused by cancer. However, this means around 10% of postmenopausal bleeding has been linked to endometrial cancer (womb cancer)⁷. This is why it is essential to put your health first and get checked as soon as you notice heavy or light bleeding after menopause. With early detection, it will mean early management and a better prognosis. 

Endometrial cancer is the 4th most common cancer in women and is more common in women who go through menopause after the age of 55⁸.  

We cover the ins and outs of womb cancer here!

Do I need to make a GP appointment if I’m experiencing bleeding after menopause?

Most definitely! 

Your GP will get a good understanding of your symptoms and should refer you to gynaecologist or directly to a specialist postmenopausal bleeding clinic. 

This is usually done via a 2-week wait pathway which means you should receive an appointment within 2 weeks. 

Your specialist doctor or clinic is likely to do a transvaginal ultrasound to see if they can detect a specific cause of the postmenopausal bleeding. If this scan does not detect anything, they may do a hysteroscopy (a small camera into the womb via the vagina and cervix) to directly visualise the womb for any problems and at the same time take a biopsy of the womb lining to test. 

Whatever the cause, you’re in safe hands at the clinic, and if they have found a cause they are usually able to suggest treatment there and then