Post-menopausal bleeding requires prompt medical evaluation to identify causes such as tissue thinning, benign growths, hormone therapy effects, or cancer, ensuring early diagnosis and effective treatment.
Post-menopausal vaginal bleeding needs a doctor’s attention. Most of the time, it’s not a serious issue, but checking it out is important since it might signal something more severe. It is often the main sign of endometrial cancer or uterine cancer, which is treatable if caught early. Early detection is crucial for better outcomes and improved prognosis.
Post-menopausal bleeding has several possible causes. One common reason is a condition called genitourinary syndrome of menopause, also known as genitourinary atrophy or vaginal atrophy. This happens when the tissues in the uterus, vagina, and vulva get thinner during the menopause transition. These tissues lose moisture and can lead to abnormal vaginal bleeding, especially after sexual activity.
Some risk factors that can cause postmenopausal vaginal bleeding include:
- Benign growths — Endometrial polyps are harmless lumps that form inside the uterus. Hormonal shifts often cause them. Uterine leiomyomas, also known as fibroids, are common and typically occur during the childbearing years. These fibroids may shrink or disappear after menopause. However, in some cases, they persist even after menopause and might lead to bleeding.
- Hormone therapy — Postmenopausal women taking estrogen therapy for menopause symptoms often deal with some vaginal spotting. The use of exogenous estrogen without progesterone (unopposed estrogen) can increase endometrial cancer risk. If the bleeding is new, recurs, or occurs at unusual times during your treatment, consult your doctor about adjusting your hormone levels or exploring alternative treatment options.
- Cancer — Endometrial cancer causes around 5% to 10% of postmenopausal bleeding cases. Cervical and vaginal cancers can also lead to bleeding, which are types of gynecologic malignancy.
Less frequent reasons include uterine lining infections like endometritis or physical injuries. It is essential to confirm if the bleeding is coming from the vagina and not the bladder or rectum. Bleeding from those areas could point to different illnesses, including colon cancer.
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Tests to diagnose postmenopausal bleeding
To find out what is causing the abnormal uterine bleeding, your doctor performs a pelvic exam and could suggest a Pap test to check for cervical cancer, along with a transvaginal ultrasound. Ultrasound is used to assess any unusual endometrial thickness, also known as the endometrial stripe. If they detect thickening, they might perform an endometrial sampling or biopsy. This test obtains a small piece of tissue from the uterus using a thin tube inserted through the cervix for examination.
Depending on the results of these tests, they might do more tests like:
- Hysteroscopy — Your doctor could use a thin tool with a light and camera (called a hysteroscope) inserted through the vagina to get a better look at the inside of your uterus.
- Uterine dilation and curettage (D&C) — Doctors perform this procedure while the patient is under anesthesia, often alongside hysteroscopy. They first widen the cervix and then use a tool called a curet. This tool, which can be sharp or work by suction, helps them remove tissue from the uterus for examination.
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To treat vaginal tissue thinning or dryness, doctors often recommend vaginal estrogen. It comes in creams or tablets and contains less estrogen than hormone replacement therapy that works throughout the body. These treatments pose minimal health risks.
If tests show cancer cells or tissue with a high risk of cancer, such as atypical hyperplasia, doctors might need to perform surgery to take out the affected areas. Sometimes, if the endometrial lining becomes unusually thick (endometrial hyperplasia), a healthcare provider may suggest removing the entire uterus through a hysterectomy.
There are cases where tests cannot find an exact cause of bleeding after menopause. But if the bleeding continues or starts again, it is important to keep talking with your physician.
Postmenopausal vaginal bleeding can be an early sign of endometrial cancer or endometrial adenocarcinoma. When caught early, removing the uterus through a hysterectomy can often cure this type of cancer.
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High estrogen levels — The ovaries make two main female hormones called estrogen and progesterone. When estrogen levels go up but progesterone does not rise, it can lead to changes in the endometrium, increasing cell proliferation and mitotic activity. Different health issues, like polycystic ovarian syndrome and obesity (high body mass index), can cause this imbalance. Using postmenopausal hormone therapy with only unopposed estrogen and no progesterone can also raise the chance of getting endometrial cancer.
Longer menstrual years — Women who experience early menarche (getting their first period before turning 12) or go through late menopause (higher age at menopause) are more likely to develop endometrial cancer. This is due to prolonged exposure to endogenous estrogen.
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Tamoxifen use — Doctors often prescribe Tamoxifen to treat and even prevent breast cancer. It has a downside, though. This medication can raise the risk of endometrial cancer in postmenopausal women. Still, its ability to combat breast cancer is more important than the small chance of developing endometrial cancer for most patients.
Understanding these risk factors and being aware of any abnormal vaginal bleeding or postmenopausal spotting is crucial for early detection and timely treatment of potential gynecologic malignancies. Factors that may reduce endometrial cancer risk include higher parity (number of childbirths) and oral contraceptive use. If you experience any unusual bleeding after your last menstrual period, consult with a gynecologic oncology specialist to discuss your symptoms and potential treatment options.
Source: Mayo Clinic Press (Dec. 4, 2025). What causes bleeding after menopause? https://mcpress.mayoclinic.org/women-health/what-causes-bleeding-after-menopause/
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