Non-cancerous reasons why you’re bleeding after menopause
Postmenopausal bleeding is vaginal bleeding that occurs after menopause; when periods have stopped for more than a year in women who are generally over 45 years, or in younger women whose ovaries have failed early.
The first signs of menopause may be flushing, mood changes and palpitations, and hormonal testing may diagnose menopause if you have high follicle-stimulating hormone (FSH) and low oestrogen levels. Women who are taking hormone replacement therapy (HRT) for more than six months and have irregular vaginal bleeding are considered also to have a postmenopausal bleed because this is unusual.1
There are many causes of postmenopausal bleeding and normally it is benign (not due to cancer).2 But cancer is a worrying and serious condition which needs to be ruled out as early diagnosis and treatment is vital, so with any postmenopausal bleeding, it is important to seek medical advice from your GP or gynaecologist.
Some common benign causes of postmenopausal bleeding include the following conditions detailed below.
Polyps are usually benign growths of normal tissue from the womb lining, and form in a mushroom shape of various sizes, attached to the lining by a stalk. The cause of polyps is related to an increase in the hormone oestrogen,3 which encourages the cells in the womb to grow. For this reason, polyps are common during pregnancy or when taking HRT.
Most polyps are small and do not cause any symptoms. But some polyps may rub against surrounding tissue, which may expose blood vessels on the polyp if cells are rubbed away, leading to spotting or vaginal bleeding. This bleeding can be heavy and can occur at any time, sometimes after intercourse.
One way to find out whether you have polyps is to have a test called a hysterosalpingogram, which involves injecting a dye under pressure into the uterus then taking an X-ray to see if polyps are present.
Alternatively, gynaecologists can use a small camera (hysteroscope), which is a thin tube with a light at the end, to look around the womb. The advantage of this test is that the doctor may be able to take samples or remove polyps. To do this, tiny scissors can be inserted into the scope to grab the polyp and cut it away from the womb lining.
Rarely, polyps turn cancerous and this risk increases with age,4 so sometimes the treatment is to have polyps removed, especially if they are causing troublesome symptoms such as heavy vaginal bleeding.
The tissue from the polyp is often sent to be examined under a microscope to make sure there are no cancer cells. Once a polyp has been removed it will only grow back in a minority of cases.
Endometrial hyperplasia is caused by an excess of oestrogen without progesterone, such as taking oestrogen only hormone replacement therapy. If ovulation does not occur, progesterone is not made and the womb lining will not shed.
The tissue in the womb therefore continues to grow under the influence of oestrogen, thickening and leading to endometrial hyperplasia (a thickened womb lining). Rarely, the cells are growing so rapidly that they may become abnormal and lead to cancer. A common symptom of endometrial hyperplasia is abnormal bleeding after menopause, which may or may not be heavy.
This is because the cells grow abnormally and fast, so the womb lining is often fragile and prone to exposing underlying blood vessels, leading to bleeding. Using a transvaginal ultrasound, the thickness of the womb can be imaged and endometrial hyperplasia can be diagnosed. If it’s present, the gynaecologist may use a hysteroscope to take a sample of the womb tissue to make sure there are no cancer cells.
Sometimes there may be thickened womb lining in particular areas that can be removed using a hysteroscopy or dilation and curettage (D&C), where the cervix is enlarged and womb tissue is scraped.
However, the treatment for endometrial hyperplasia is often trying to prevent it from happening in the first place, which involves stopping unopposed oestrogen.
This means adding progestin or progesterone to HRT courses. There is some suggestion that endometrial cancers happen more often in people who are overweight, so losing weight may also help.
Endometrial atrophy is where the womb lining is very thinned. This occurs when there is very low levels of oestrogen in the body, as is the case during menopause. This is because oestrogen is responsible for the thickening of the endometrial lining. As the womb lining thins, the underlying blood vessels are exposed which can lead to abnormal bleeding.
This may be heavy or light bleeding after menopause, or after intercourse. Endometrial atrophy may be diagnosed using a transvaginal ultrasound which can measure the thickness of the womb lining. If there are minimal symptoms, treatment for endometrial atrophy may be unnecessary. But if treatment is needed, it can be treated with oestrogen cream or pessaries.
Vaginal atrophy is a condition where the tissue forming the vaginal wall becomes very thin and dry. It is caused by a lack of oestrogen during menopause. This is because oestrogen is responsible for growth of vaginal cells and also for stimulating mucous secretions from mucosal glands in the vagina.
When there is vaginal atrophy, it may make intercourse and passing urine painful (there is less defense against urine infection, and exposed nerve cells make passing urine uncomfortable). Because the vagina is dry it may feel itchy, and friction can cause the cells to be rubbed away, exposing underlying blood vessels that may bleed.
This leads to vaginal bleeding and there may be spotting after intercourse. Symptoms of vaginal dryness may be relieved by using lubricants and vaginal moisturiser.
Alternatively, vaginal oestrogen in the form of creams or pessaries, and hormone replacement therapy may help because these all replace the lack of oestrogen. Due to dryness of the vagina, intercourse may be uncomfortable. In addition to lubrication during sex, it may be worthwhile allowing more time to become aroused before having sex in order to give more time for natural lubrication to occur.
Sexually transmitted diseases
There are a range of sexually transmitted diseases (STDs) that can cause postmenopausal bleeding, such as chlamydia, gonorrhoea, and herpes. These infections are caught by having unprotected sex and being in contact with infected genital fluid. (You can’t catch them from swimming pools, sharing towels, or using the same toilet.)
Chlamydia and gonorrhoea most commonly infect the cells in the cervix and womb, which causes inflammation, and therefore fragile blood vessels, which can bleed. There may be other symptoms associated with STDs, such as a yellow or milky white vaginal discharge, and pain on peeing with chlamydia.
There may also be pelvic pain caused by inflammation of the womb and fallopian tubes. The diagnosis can be made by a urine test or swabbing cervical discharge for culture. Treatment is with antibiotics. For chlamydia this may be with a one-time dose of azithromycin and over 95% of people will be cleared of chlamydia, provided that they take antibiotics correctly.5
As previously stated, any vaginal bleeding after menopause is considered a postmenopausal bleed and should always be checked out by your doctor to rule out any serious conditions.
Last updated July 2019
Next update due 2021
- Munro, M.G., Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations, The Permanente Journal, Winter 2014, vol 18, no.1., pp 55-70
- Nijkang, N.P., et al., Endometrial polyps: pathogenesis, sequelae and treatment, SAGE Open Medicine, 2019, 7:2050312119848247 [online], https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501471/ (accessed 8 July 2019)
- NHS Choices Health A-Z, ‘Chlamydia’, [website], 2015, https://www.nhs.uk/conditions/chlamydia, (accessed 12 December 2017).
With supporting information from
- RCOG, ‘Management of endometrial hyperplasia’, Green-top Guideline No. 67, RCOG/BSGE joint guideline, February 2016
- Mac Bride, M.B., at al., Vulvovaginal atrophy, Mayo Clinic Proceedings, January 2010, vol 85, no. 1., pp 87-94