Bleeding after menopause: possible causes and tests

Why should bleeding after menopause always be investigated?

Menopause is defined as no periods for 12 consecutive months. After that, the endometrium (the lining of the uterus) no longer bleeds normally. Any bleeding, even a light pink or brownish trace, a single episode or bleeding after sex, is therefore abnormal.

Most causes are benign. But bleeding is the main warning sign of endometrial cancer: a meta-analysis of more than 40,000 women shows that 91% of endometrial cancers present with postmenopausal bleeding, and that 9% of women who bleed have endometrial cancer. Seeing a doctor early means these cancers are diagnosed at a stage when they can usually be cured. Our gynaecological cancer care page explains this care in more detail.

What causes bleeding after menopause?

Submucosal fibroids, common before menopause, usually shrink afterwards and are a less frequent cause. Bleeding can also come from the urinary tract or the rectum: the doctor checks where it comes from.

What tests are done for postmenopausal bleeding?

1. Consultation and gynaecological examination: time since menopause, treatments (hormones, tamoxifen, anticoagulants), medical history; speculum examination of the vulva, vagina and cervix to look for a lesion or atrophy.
2. Pelvic and transvaginal ultrasound: this is the first-line test. It measures the thickness of the endometrium and looks for a polyp, a fibroid or an ovarian abnormality.
3. Endometrial biopsy: a sample taken with a thin tube passed through the cervix, during the appointment. Analysis under the microscope confirms or rules out cancer.
4. Diagnostic hysteroscopy: a thin camera passed through the cervix shows the inside of the uterus and allows targeted samples. It is used if a biopsy is not possible or inconclusive, or if a localised lesion is suspected.
5. Saline infusion sonography: an ultrasound with saline injected into the uterus, which gives a clearer view of a polyp.
6. Cervical smear test if screening is not up to date. It screens for cervical lesions but does not examine the endometrium: a normal smear does not rule out endometrial cancer.

What does endometrial thickness on ultrasound mean?

In a postmenopausal woman who is bleeding, a thin endometrium is reassuring. French guidelines (French College of Gynaecologists and Obstetricians, CNGOF, and GEMVi, 2021), written for bleeding on menopausal hormone therapy, use a threshold of 4 mm: after a single episode with an endometrium of 4 mm or less, monitoring is possible; above 4 mm, or if bleeding recurs, further investigations (hysteroscopy and analysis of the endometrium) are recommended.

This threshold has limits: it is less reliable on sequential hormone therapy (the scan is then done at the end of the progestogen phase), on tamoxifen, or when the endometrium is hard to see. Bleeding that persists or comes back must be investigated, whatever the thickness measured.

What increases the risk of endometrial cancer?

Some situations make investigation all the more important, because they expose the endometrium to unopposed oestrogen or to an inherited predisposition:

• overweight and obesity, the most important factor: after menopause, fat tissue continues to produce oestrogen;
• diabetes and high blood pressure;
• oestrogen taken without a progestogen by a woman who still has her uterus;
• tamoxifen, used after breast cancer, which stimulates the endometrium;
• late menopause, never having been pregnant, polycystic ovary syndrome;
• family predisposition, particularly Lynch syndrome (bowel and endometrial cancers in the family, often at a young age).

On tamoxifen, the endometrium often looks thickened on ultrasound without any disease, which makes interpretation more difficult: any bleeding should be reported to your gynaecologist and your oncologist. Follow-up after cancer is covered in our article on follow-up after uterine cancer.

How is postmenopausal bleeding treated?

• Atrophy: vaginal moisturisers, lubricants, low-dose vaginal oestrogen once the diagnosis is confirmed (see vaginal dryness).
• Bleeding on hormone therapy: checking the treatment is taken correctly, adjusting the regimen; repeated bleeding is investigated.
• Polyp: removal by operative hysteroscopy, through the vagina with no incision, with routine analysis of the polyp.
• Hyperplasia: progestogen treatment and monitoring, or hysterectomy depending on atypia and the overall situation.
• Endometrial cancer: staging (notably pelvic MRI), then treatment, most often surgery (hysterectomy with removal of the ovaries and tubes, assessment of the lymph nodes), sometimes followed by radiotherapy or other treatments. The decision is made at a multidisciplinary team meeting, in line with European guidelines.

At the practice: the average waiting time for an appointment is one week to 10 days (except during holiday periods); the ultrasound and, if needed, diagnostic hysteroscopy can be carried out at the practice.

When is postmenopausal bleeding an emergency?

Bleeding after menopause calls for a prompt appointment, within a few days. Go to A&E or, in France, call 15 (SAMU) or 112 (or your local emergency number) if you have:

• heavy bleeding (soaking a pad in less than an hour, large clots);
• faintness, pallor, breathlessness, palpitations;
• severe abdominal pain or fever;
• heavy bleeding while on anticoagulants.

Outside these situations, do not let several weeks go by: note the date, amount and circumstances of the bleeding, as well as your current treatments, and bring this information to your appointment.

Frequently asked questions

General information article: it does not replace a medical consultation. In an emergency, call 15 or 112 in France, or your local emergency number.