After menopause
Post-menopausal bleeding
Any bleeding after menopause should be assessed. Most causes are benign, but the first priority is to rule out endometrial precancer or cancer safely and quickly.
Quick definition
Medical meaning: any uterine bleeding after menopause (usually after 12 months without periods), apart from expected scheduled withdrawal bleeding on cyclic combined hormone therapy.
Most bleeding is not cancer. Common causes include atrophy and polyps, but assessment is still essential every time.
When to seek urgent care
- Heavy bleeding with dizziness, fainting, weakness, or shortness of breath.
- Bleeding with severe pelvic pain, fever, offensive discharge, or feeling very unwell.
- Bleeding while taking anticoagulants (blood thinners) that is ongoing or increasing.
- Recurrent bleeding after an initial “normal” result should be reassessed promptly.
If you are unsure, contact reception or your nearest emergency centre.
Most common causes
Endometrial and vaginal atrophy, and endometrial polyps, are common benign causes. Endometrial hyperplasia and cancer are less common but must be excluded first.
Atrophy (vaginal or endometrial)
Low-oestrogen tissue after menopause can become thin and fragile, causing light spotting or bleeding.
Endometrial polyps
Polyps are a common structural cause. Most are benign, but tissue diagnosis is often needed.
Endometrial hyperplasia (EIN)
Thickened endometrium can cause bleeding and may be precancerous, so it needs structured management.
Endometrial cancer
The overall risk is not high, but this must be excluded in all post-menopausal bleeding episodes.
Hormone therapy or medication-related bleeding
Bleeding can occur on some HRT regimens and with some medicines, but persistent bleeding still needs full evaluation.
Cervical, vaginal, or non-uterine sources
Sometimes bleeding is from local tissue, cervix, urinary tract, or bowel, not the uterine cavity.
What the assessment usually includes
Step 1
History and risk check
We review timing/amount of bleeding, medicines (including HRT/tamoxifen/anticoagulants), and risk factors such as obesity, diabetes, and family history.
Step 2
Pelvic and speculum examination
This helps identify lower-tract causes and checks for visible cervical or vaginal lesions that may need biopsy.
Step 3
Endometrial test
Either endometrial biopsy or transvaginal ultrasound is used as the initial endometrial test. Biopsy is often preferred for tissue diagnosis.
Step 4
Further tests if bleeding recurs
Persistent or recurrent bleeding usually needs re-evaluation, often with hysteroscopy and/or saline sonography, even after an initial reassuring test.
What treatment may involve
Treatment depends on the diagnosed cause. Many people need minimal treatment once serious causes are excluded, but follow-up remains important.
- Atrophy-related bleeding: local treatments and tissue support options can reduce ongoing spotting and discomfort.
- Polyps: removal and histology may be recommended.
- Hyperplasia or cancer: specialist pathway with targeted treatment and follow-up.
- Medication-related bleeding: regimen review, dose adjustments, or alternative plans where appropriate.
- Recurrent bleeding: repeat assessment, even when initial tests were reassuring.
Helpful for your visit: bring your medication list, prior scan/biopsy reports, and a timeline of bleeding episodes.
Common questions
Frequently asked questions
Is post-menopausal bleeding always cancer?
No. Most causes are benign, especially atrophy and polyps. But every episode still needs formal assessment.
I only had light spotting once. Do I still need a check?
Yes. Even light spotting after menopause should be evaluated at least once.
Will I always need a biopsy?
Not always. Initial endometrial evaluation may be biopsy or transvaginal ultrasound, depending on your clinical picture.
If my first test is normal but bleeding returns, should I come back?
Yes. Recurrent bleeding should be re-investigated, because persistent symptoms can still indicate significant endometrial pathology.
Can hormone therapy cause bleeding?
Yes, some hormone regimens can cause bleeding patterns. Persistent or unexpected bleeding still needs structured evaluation.
Need a clear plan today? We can assess urgency, arrange the right tests, and explain results in plain language.
Still unsure? We can map your symptoms to the right pathway and agree on practical next steps.