Bleeding After Menopause — Why You Need to Call Your Doctor Today

No. Once you have gone 12 consecutive months without a menstrual period, you have reached menopause. After that milestone, any vaginal bleeding — whether it's a full flow, light spotting, or pink-tinged discharge — is considered abnormal and requires medical evaluation.

This is a bright-line rule in medicine, and it exists for a critical reason: postmenopausal bleeding is one of the earliest warning signs of endometrial cancer. While most cases turn out to be caused by something benign, the only way to know for sure is through proper diagnostic workup.

About 4–11% of postmenopausal women experience unexpected bleeding. Of those women, roughly 10% will be diagnosed with endometrial cancer. That means the vast majority — about 90% — have a non-cancerous cause. But those odds are not reassuring enough to justify waiting.

The good news: when endometrial cancer is caught at Stage I (before it spreads beyond the uterus), the 5-year survival rate exceeds 90%. Early detection is genuinely lifesaving here. The test is straightforward — typically a transvaginal ultrasound and possibly an endometrial biopsy — and the peace of mind is worth the appointment.

The most common causes of bleeding after menopause are benign, but every case still requires evaluation to rule out cancer.

Vaginal or endometrial atrophy is the single most frequent cause. As estrogen levels drop after menopause, the tissues of the vagina and uterine lining become thin, dry, and fragile. Even minor friction — from physical activity, a pelvic exam, or intercourse — can cause spotting or light bleeding.

Endometrial or cervical polyps are noncancerous growths that can develop on the lining of the uterus or cervix. They're common in postmenopausal women and can bleed spontaneously or with minimal contact.

Hormone replacement therapy (HRT) is another frequent cause. If you're taking estrogen — especially without adequate progesterone — it can stimulate the endometrial lining and cause breakthrough bleeding. This is particularly common in the first 6 months of starting or changing HRT.

Endometrial hyperplasia occurs when the uterine lining becomes abnormally thick, usually due to unopposed estrogen. While not cancer, some types of hyperplasia (atypical) are considered precancerous and need treatment.

Endometrial cancer accounts for roughly 10% of postmenopausal bleeding cases. Risk factors include obesity, diabetes, late menopause, never having been pregnant, and a history of unopposed estrogen use. The most important thing to remember: early-stage endometrial cancer is highly treatable.

Your doctor will follow a systematic approach to determine the cause of postmenopausal bleeding, and the process is usually straightforward and well-tolerated.

The first step is typically a transvaginal ultrasound. A small probe is inserted into the vagina to measure the thickness of your endometrial lining. In postmenopausal women not on HRT, a lining thinner than 4–5 mm is generally reassuring and makes cancer very unlikely.

If the lining is thickened or the ultrasound is inconclusive, the next step is usually an endometrial biopsy. This is an in-office procedure where a thin, flexible tube (pipelle) is inserted through the cervix to collect a small sample of uterine lining tissue. It takes about 60 seconds and feels like strong menstrual cramps. The tissue sample is sent to a lab to check for abnormal or cancerous cells.

In some cases, your doctor may recommend a sonohysterography (saline-infusion ultrasound) to get a clearer picture of the uterine cavity, or a hysteroscopy — where a tiny camera is inserted through the cervix to directly visualize the lining and remove any polyps.

Blood work may also be ordered to check hormone levels, thyroid function, and clotting factors. If you're on HRT, your doctor will review your regimen to determine whether it could be the cause.

The entire diagnostic process usually takes 1–2 weeks from initial appointment to results. Try not to catastrophize during the wait — remember, 90% of cases are benign.

Yes, hormone replacement therapy is a well-recognized cause of postmenopausal bleeding, and it's often the explanation — but it should never be assumed without proper evaluation.

If you're on combined continuous HRT (estrogen plus progesterone taken daily), irregular bleeding or spotting is common in the first 3–6 months as your body adjusts. Up to 40% of women experience some bleeding during this initial period. If bleeding persists beyond 6 months, or if it starts after you've been stable on HRT for a while, it needs investigation.

If you're on cyclical HRT (estrogen daily with progesterone for 10–14 days per month), you'll typically have a predictable withdrawal bleed at the end of each progesterone phase. Any bleeding outside this expected pattern should be reported.

Estrogen-only HRT without progesterone (only appropriate for women who've had a hysterectomy) doesn't cause withdrawal bleeding, but can still cause spotting if the dose is high or if there's residual endometrial tissue.

The key point: while HRT is a common and often benign explanation for postmenopausal bleeding, your doctor should still rule out other causes — especially if the bleeding pattern changes, becomes heavier, or occurs after a stable period on the same regimen. Never adjust your HRT dose on your own to manage bleeding; always discuss changes with your prescriber.

The most common — and often the only — early sign of endometrial cancer is abnormal vaginal bleeding. In postmenopausal women, this means any bleeding at all. In perimenopausal women, it may present as heavier periods, bleeding between periods, or periods that become irregular in a new way.

Other symptoms that can occur, especially as the disease progresses, include watery or blood-tinged vaginal discharge (even without frank bleeding), pelvic pain or pressure, pain during intercourse, unexplained weight loss, and difficulty or pain with urination.

However, many women with early-stage endometrial cancer have no symptoms other than bleeding. This is actually a silver lining — because bleeding tends to occur early in the disease, most endometrial cancers are caught at Stage I, when they're still confined to the uterus.

Risk factors that increase your chances include obesity (fat tissue produces estrogen, which stimulates the uterine lining), type 2 diabetes, polycystic ovary syndrome (PCOS), early menstruation (before age 12), late menopause (after age 55), never having been pregnant, tamoxifen use, Lynch syndrome, and a history of taking estrogen without progesterone.

The single most important takeaway: if you experience any postmenopausal bleeding, get evaluated promptly. Early endometrial cancer is one of the most treatable gynecologic cancers, with Stage I survival rates exceeding 90%. Delay is the biggest risk factor you can actually control.

Treatment depends entirely on the underlying cause, which is why accurate diagnosis comes first.

For vaginal or endometrial atrophy, the most common cause, treatment typically involves vaginal estrogen (cream, ring, or tablet). Vaginal estrogen restores tissue thickness and elasticity with minimal systemic absorption, making it safe for most women — even many with a history of breast cancer, though this should be discussed with your oncologist.

Endometrial or cervical polyps are usually removed during a hysteroscopy — a minimally invasive outpatient procedure. Recovery is quick, and most polyps are benign.

If HRT is the cause, your doctor may adjust the type, dose, or delivery method of your hormones. Sometimes switching from oral to transdermal estrogen, or adjusting the progesterone component, resolves the bleeding.

Endometrial hyperplasia without atypia can often be treated with progesterone therapy (oral or via a Mirena IUD) to thin the lining. Hyperplasia with atypia is considered precancerous and may require a hysterectomy, especially in postmenopausal women.

Early-stage endometrial cancer is typically treated with a hysterectomy (removal of the uterus) and bilateral salpingo-oophorectomy (removal of fallopian tubes and ovaries). Many early cases don't require radiation or chemotherapy afterward. The prognosis for Stage I disease is excellent.

Regardless of the cause, follow-up monitoring is important. Your doctor will likely want to confirm that bleeding has resolved and may schedule periodic ultrasounds or exams.