AFTER MENOPAUSE
Finding blood after your periods have stopped can be unsettling. Most causes are non-cancerous, but even a small amount or a single episode deserves a check. We work out where the bleeding is coming from and agree the right investigations.
WHAT COUNTS?
Postmenopausal bleeding usually means vaginal bleeding after 12 months without a natural period. It can be pink or brown staining, a few spots when wiping, bleeding after sex, or a heavier flow. Tell us even if you are unsure whether it is blood.
If contraception, HRT, a hysterectomy or another treatment has changed your periods, the timing of menopause may be less clear. You can still ask for an assessment without working this out yourself.
A planned withdrawal bleed on sequential HRT is a different situation. Unexpected bleeding needs advice based on the regimen, timing, amount and your health history. Early spotting should be discussed; it is not a reason to ignore heavy, prolonged or changing bleeding.
POSSIBLE CAUSES
The pattern alone cannot reliably identify the cause. We consider the womb lining, cervix, vagina and external skin; occasionally blood is coming from the urinary tract or bowel.
Lower oestrogen can make the vaginal lining or womb lining thin and fragile. Vaginal dryness and friction may contribute, but apparent dryness does not remove the need to assess unexplained bleeding.
Small growths in the womb or cervix can cause spotting. Most are benign. A womb polyp may need removal and examination in the laboratory, because its appearance on a scan cannot establish the diagnosis by itself.
Hyperplasia is an overgrowth of the lining, diagnosed from tissue. Hyperplasia without atypia differs from atypical hyperplasia / EIN, a precancerous change. A thick measurement on ultrasound is a finding to investigate, not a diagnosis of either condition.
Cancer is a less common cause, but finding it early is an important reason to investigate. The assessment looks for womb-lining cancer and for concerning changes in the cervix, vagina or vulva where relevant.
HRT, tamoxifen and blood-thinning medicines are relevant to the assessment. A medicine may contribute to bleeding while another cause is also present. Do not stop prescribed blood thinners on your own.
Inflammation, infection, a skin split or a visible lesion can bleed. Lichen sclerosus may coexist with menopausal dryness; a persistent sore, lump or focal bleeding area needs its own examination and sometimes a biopsy.
YOUR CONSULTATION
We discuss when bleeding began, how much there has been, whether it follows sex, and any pain, discharge or urinary symptoms. Bring your medicines and previous results. Menopause timing, diabetes, weight, previous lining problems and relevant family history help guide the assessment.
Looking at the vulva, vagina and cervix can help locate the source. A speculum examination may be needed. Tell me about dryness, pain, past difficult examinations or anything that would help you feel more comfortable. You can ask for a chaperone and pause or stop.
Ultrasound and a tissue sample answer different questions and are often used together. Your symptoms, risk factors, medicines and the quality of the scan guide the plan. Persistent or recurrent bleeding needs further assessment even after reassuring results.
UNDERSTANDING THE TESTS
You may need more than one test. We explain the reason for each and discuss how it will be done.
An internal probe produces pictures of the womb and its lining. It can show thickening, a possible polyp and whether the lining is seen clearly. It does not examine individual cells.
A fine tube passed through the cervix takes a small sample of the womb lining. A laboratory checks the tissue for abnormal cells. Sometimes the sample is too small to give a clear answer.
A thin camera passes through the cervix to inspect the cavity. It can locate a polyp or another focal change and guide sampling. Polyp removal may be planned at the same time, with your consent.
Simplified illustrations of what the tests show, rather than anatomical or procedural instructions.
A thin, clearly seen lining can be reassuring, but a measurement alone is not a guarantee. In April 2026, ACOG updated its US guidance to recommend ultrasound and tissue sampling for most patients with postmenopausal bleeding. The tests are considered together with your individual circumstances; HRT-related bleeding has additional, regimen-specific guidance.
If the lining cannot be measured reliably, a focal abnormality is suspected, or bleeding continues or returns, further investigation may be needed. We discuss why a biopsy or hysteroscopy is recommended even if a previous scan sounded reassuring.
Biopsy and hysteroscopy can cause cramping, and some people experience significant pain. Discuss pain relief and whether an awake procedure, sedation or anaesthesia would suit you before arranging the procedure. Available options depend on the procedure and setting. You can ask to stop an awake examination or procedure.
A blood count may help if bleeding has been heavy or prolonged. Cervical screening, swabs or urine tests may be appropriate for separate findings. A normal cervical screening result or a hormone blood test does not exclude disease in the womb lining.
AFTER INVESTIGATION
We review whether the findings explain the bleeding and whether treatment is needed. Agree how to get back in touch if it happens again. A previous normal result should not stop you reporting a new episode.
“Not enough tissue” is not the same as a confirmed normal biopsy. It can happen with a very thin lining. The scan, risk factors and whether bleeding persists determine whether another sample or hysteroscopy is needed.
Contact the practice promptly, even if the first scan or biopsy was reassuring. A small sample can miss a focal problem such as a polyp. Further assessment may include hysteroscopy with targeted sampling; saline ultrasound is sometimes useful for clarifying the cavity.
Before leaving, agree how results will be communicated and when to follow up. Contact the practice if the agreed time passes. Do not assume that no news means the result is normal.
TREATMENT
Confirmed vaginal tissue fragility may improve with local care or prescribed vaginal oestrogen. A polyp may be removed and sent to the laboratory. An HRT-related pattern may improve with a supervised regimen change. Some reassuring findings need observation and a clear return plan.
Hyperplasia without atypia may be managed with progestogen treatment and repeat sampling. Atypical hyperplasia / EIN or cancer needs a specialist treatment discussion, which may include surgery. These diagnoses and their treatment should be explained individually.
PRACTICAL PREPARATION
You do not need a perfect diary or tests arranged in advance.
Keep a simple record and use the urgent advice above if bleeding increases or you feel unwell. Ask for an individual plan for HRT or other medicines; do not make repeated changes to try to explain away the bleeding. If bleeding stops before your visit, keep the appointment.
Preparation differs between a consultation, an office biopsy and a procedure with anaesthesia. Follow the specific instructions you are given, including any fasting, transport or medicine advice.
COMMON QUESTIONS
Yes. Arrange an assessment even if it was a small amount, happened only once or has stopped. You do not need to wait for fresh red bleeding.
Many patients are offered both ultrasound and sampling of the womb lining. The decision depends on your history, medicines, scan findings and symptoms. We explain the reason for the proposed tests, their limitations and your options for comfort.
Fragile tissue can bleed with friction, but other causes may coexist. An examination helps establish the source. Treating dryness should not replace assessment of unexplained postmenopausal bleeding.
Bleeding still needs assessment, although the investigation is different. We clarify whether the cervix was retained and examine the remaining tissues. There is no womb lining to sample after the uterus has been removed.
General information to support your consultation. Your assessment and treatment plan are individual.
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Further reading: NHS: bleeding after menopause · ACOG: 2026 evaluation update · RCOG: hysteroscopy and your choices · RCOG: endometrial hyperplasia.