If you have had any bleeding after menopause, please read this carefully. Postmenopausal bleeding is one of the few symptoms in gynaecology where we really do mean “do not wait”. Most of the time it turns out to be nothing serious. But because a small number of cases are due to cancer of the lining of the uterus, every case needs to be checked, and sooner is always better.
What is postmenopausal bleeding?
Menopause is officially diagnosed when you have gone 12 months in a row without a period. Any bleeding at all after that point counts as postmenopausal bleeding. This includes:
1. A full period-like bleed.
2. Light spotting that stops in a day or two.
3. A single pink or brown stain on toilet paper.
4. Bleeding during or after sex.
5. Bleeding after a bowel motion.
There is no amount of bleeding after menopause that we consider too small to check. Even a one-off spot deserves an appointment.
Why is bleeding after menopause taken so seriously?
The main reason is cancer of the lining of the uterus, called endometrial cancer. It is the most common gynaecological cancer in Australia. About 1 in 10 women with postmenopausal bleeding will be found to have endometrial cancer. When caught early, the outcomes are usually very good. When caught late, treatment is harder. That is the whole reason for the urgency.
There are also other serious causes we want to rule out, such as cancer of the cervix or ovary. These are rarer, but a specialist assessment covers all of them at the same visit.
What causes postmenopausal bleeding?
Vaginal atrophy
This is the most common cause. After menopause, the vaginal walls become thin and fragile due to low oestrogen. They can bleed easily, especially after sex or straining. See our blog on effective vaginal dryness treatment for more.
Endometrial or cervical polyps
These are small, usually non-cancerous growths. They are a common cause of light bleeding or spotting. They can almost always be removed with a short procedure.
Thickened endometrium (endometrial hyperplasia)
Sometimes the lining of the uterus becomes thicker than it should be. This can cause bleeding. Depending on the type, hyperplasia may be treated with hormones or by a hysterectomy if the risk of cancer is high.
HRT-related bleeding
Some types of HRT cause light scheduled bleeding. Unscheduled bleeding on HRT is more common in the first 3 to 6 months but should still be checked to rule out other causes.
Endometrial cancer
This is the most important cause to rule out. The risk is higher in women who are overweight, who have diabetes, who have never had children, or who have a family history. Early diagnosis is what makes the difference, which is why postmenopausal bleeding is never ignored.
Other causes
Infections, trauma, medications (such as blood thinners), and conditions of the urinary tract or bowel can occasionally be mistaken for vaginal bleeding. A specialist examination sorts this out.
What happens at your appointment?
Step 1: History and examination
Your specialist will ask when the bleeding started, how much, whether anything triggered it, and about any other symptoms. A gentle pelvic examination will check the vulva, vagina, and cervix. This is usually not uncomfortable and takes only a few minutes.
Step 2: Pelvic ultrasound
We advise you have a pelvic ultrasound organized through your GP to measure the thickness of the lining of the uterus. In most postmenopausal women, a very thin lining is a reassuring sign. A thicker lining could be indicative of hyperplasia or malignancy.
Step 3: Biopsy of the uterine lining
A tiny sample of the lining is taken using a thin suction tube passed through the cervix. This is often done in the clinic at the same visit as the ultrasound. Most women describe it as a strong cramp for a few seconds.
Step 4: Hysteroscopy if needed
If the ultrasound suggests a polyp, a fibroid, or something that cannot be sampled with a simple biopsy, a hysteroscopy is arranged. This is a short procedure where a small camera is used to look inside the uterus and take targeted samples. It can be done under light anaesthetic at a day hospital.
Step 5: Cervical check if needed
If the bleeding may be coming from the cervix, a colposcopy and sometimes a biopsy of the cervix is arranged. Our cervical screening test page explains how we assess the cervix.
Treatment based on the cause
Treatment depends entirely on what we find.
1. Vaginal atrophy is usually treated with vaginal oestrogen, non-hormonal options, or in some cases PRP or laser-assisted PRP delivery.
2. Polyps are usually removed with a short hysteroscopy procedure.
3. Hyperplasia may be treated with the Mirena IUD, oral progesterone, or in some cases surgery.
4. HRT-related bleeding may be managed by adjusting the type or dose of HRT.
5. Endometrial cancer is managed by a gynaecology oncology team. Early stage disease usually has very good outcomes. Your specialist will refer and support you through the next steps.
When is bleeding NOT postmenopausal?
If you are still in perimenopause and have not yet gone 12 months without a period, irregular bleeding is often a normal part of the transition. It is still worth seeing a specialist if periods become very heavy, very long, or if you have bleeding between periods. After menopause is officially reached, the threshold for action becomes much lower.
About Northside Gynaecology and postmenopausal bleeding assessment
Northside Gynaecology is a specialist gynaecology practice in Brisbane. Our team, led by Dr Archna Saraswat, FRANZCOG, prioritises postmenopausal bleeding referrals so you are seen quickly. In most cases we can do the examination, ultrasound, and biopsy at the same visit, so you do not have to wait weeks between tests. We consult from Kedron, North Lakes, and Caboolture Private Hospital.
Frequently asked questions
What counts as postmenopausal bleeding?
Any bleeding at all from the vagina after you have gone 12 months without a period counts as postmenopausal bleeding. Even a single spot or a pink stain on toilet paper is worth checking. There is no safe amount of bleeding after menopause.
Is postmenopausal bleeding always serious?
Not always. About 1 in 10 cases of postmenopausal bleeding are due to endometrial cancer. The other 9 are due to things like vaginal atrophy, polyps, or HRT. But because of that 1 in 10, every case needs to be checked, usually within a few weeks.
How soon do I need to see a doctor for bleeding after menopause?
As soon as possible. Guidelines suggest within 2 to 4 weeks of the first bleed. The sooner the cause is found, the better the outcome if it does turn out to be something serious.
What tests will I need?
The usual first steps are a specialist examination, a pelvic ultrasound, Cervical screening test and often a biopsy of the lining of the uterus. This is sometimes done at the same visit using a small suction device. If more detail is needed, a hysteroscopy may be arranged.
Can HRT cause bleeding after menopause?
Yes. Some types of HRT cause light scheduled bleeding, especially cyclical regimens. Unscheduled bleeding on HRT still needs to be checked by a specialist to rule out other causes.
Is a hysterectomy always needed?
No. Most causes of postmenopausal bleeding are treated without hysterectomy. Only certain diagnoses, such as endometrial cancer or high-risk hyperplasia, usually need hysterectomy.
What if the biopsy is normal but the bleeding continues?
If the first set of tests is normal and the bleeding keeps happening, a hysteroscopy with targeted biopsy is usually the next step. Your specialist will plan this with you.
Book an urgent appointment for postmenopausal bleeding
Postmenopausal bleeding is one of the few situations in gynaecology where quick action truly makes a difference. If you have had any bleeding at all after menopause, please book now.
Call us on 07 3054 4687 or use the contact page. Please mention that this is for postmenopausal bleeding so we can prioritise your appointment. Ask your GP for a referral if you have time, but do not delay the appointment if you cannot get one immediately. We can discuss this when you call.