After you go through menopause — defined as a full year without a menstrual period — it's normal to experience hot flashes, weight gain and reduced libido. But the last thing you expect to see is vaginal bleeding.
Approximately 10% of people have vaginal bleeding after menopause. It accounts for more than 60% of all postmenopausal gynecologic visits and is more commonly reported in the first few years following menopause.
The bleeding can range from light pink or brown spotting to a heavy period-like flow and typically does not cause any pain. But bleeding after menopause is never normal and requires medical evaluation to identify the underlying cause.
Here's what you need to know:
Possible causes of vaginal bleeding after menopause
Bleeding after menopause tends to signal an underlying issue in your uterus or cervix. In most cases, the cause can be quickly addressed and treated, but medical evaluation is critical for guiding next steps.
Postmenopausal bleeding can be caused by:
1. Endometrial atrophy
As you age, the lining of the uterus (endometrium) can become thin and delicate, known as endometrial atrophy. Low estrogen levels are typically to blame.
Endometrial atrophy is the most common cause of postmenopausal bleeding, responsible for 60% of cases. Bleeding tends to occur after sexual intercourse, when friction can cause the thin endometrial tissue to become irritated.
The good news is that endometrial atrophy is treatable with medication. Your physician may recommend topical estrogen cream or hormone replacement therapy.
2. Polyps
Polyps are typically benign (noncancerous) growths. Polyps that cause vaginal bleeding after menopause may occur in several places, including:
- Cervix
- Cervical canal
- Endometrium
- Uterine wall
The location of the polyp may affect when you bleed and how much. For instance, a polyp on your cervix may only cause bleeding after sex.
Polyps may be removed with a surgical procedure. While most polyps are noncancerous, polyps that occur after menopause carry a higher risk of being precancerous or cancerous.
3. Endometrial hyperplasia
Endometrial hyperplasia is a condition that occurs when hormonal imbalance — too much estrogen and not enough progesterone — causes the lining of the uterus to grow and thicken. Endometrial hyperplasia is most likely to happen when ovulation stops with menopause, because your body no longer makes progesterone.
To treat endometrial hyperplasia, your physician may prescribe progestin — a synthetic form of progesterone — which causes the endometrium to shed and helps balance your hormones.
Endometrial hyperplasia can have serious long-term effects if left untreated. The cells in the thickened uterine lining can become abnormal and lead to cancer. Your physician may recommend regular surveillance and biopsies since endometrial hyperplasia increases the risk of endometrial cancer.
4. Endometrial cancer
Vaginal bleeding is the most common symptom of endometrial cancer after menopause. Approximately 90% of postmenopausal people diagnosed with endometrial cancer report vaginal bleeding as an early symptom.
Anyone can develop endometrial cancer, and the risk increases as you age. Other factors that can also increase the risk include:
- Early age at first menstruation or older age at menopause
- History of diabetes, high blood pressure, gallbladder disease or thyroid disease
- Long-term use of high-estrogen medications
- Never having been pregnant or have a history of infertility
- Obesity
- Polycystic ovary syndrome (PCOS)
- Treatment with the drug tamoxifen
When diagnosed in an early stage, endometrial cancer can often be successfully treated. Treatment typically involves surgery to remove the cervix, uterus, ovaries and fallopian tubes.
Other possible causes of postmenopausal bleeding
While less common, bleeding after menopause may be associated with:
- Infection in the uterus or cervix
- Medication side effects
- Other types of cancer
There is also always a chance that what may seem like uterine bleeding is actually caused by a non-gynecologic issue. Bleeding from the vagina can stem from the urethra, bladder or gastrointestinal tract.
When to see a medical professional about postmenopausal bleeding
Any spotting or bleeding following menopause should be evaluated by a medical professional. Be prepared to answer questions about:
- Your symptoms, including bleeding intensity, duration and frequency
- When menopause occurred
- Your medications
- Your medical history and other medical conditions
Depending on the information you provide, you may have a pelvic examination, ultrasound imaging or diagnostic procedures to identify the underlying cause. Understanding what is causing the bleeding is the first step in treating the issue.
