What causes bleeding after menopause?

About 10% of women over the age of 55 experience postmenopausal bleeding. In many cases, bleeding or spotting after menopause is due to benign causes. However, you should see your healthcare provider for any postmenopausal bleeding as it could indicate a more serious condition. More than 90% of women who have endometrial cancer experience bleeding.

No, your periods can’t restart once you have gone through menopause.

Menopause has occurred once you have gone without a period for 12 months in a row and there is no other medical cause for your lack of menstruation. If you've gone through menopause, your ovaries no longer release eggs and you won’t get periods anymore. However, menstruation may start and stop during perimenopause, the period of years leading up to menopause.

Due to changes in hormone levels, your body goes through many changes during the stages of menopause. Vaginal bleeding after menopause is often due to these changes. The following are some reasons why you might experience postmenopausal bleeding:

Vaginal atrophy

After menopause, the vaginal walls and/or the lining of the uterus may thin. This is known as atrophy. When atrophy occurs, the lining becomes more delicate and prone to tears and lacerations, especially during sexual intercourse. Vaginal dryness can worsen the problem and make injuries more likely. Just as a wound to the skin elsewhere on your body can cause bleeding, these lacerations can result in bleeding or spotting.

If vaginal atrophy is the cause of postmenopausal bleeding, your healthcare provider can prescribe topical estrogen creams, suppositories, rings or tablets. Using vaginal moisturizers and water-based lubricants may also help.

Hormone therapy

In some cases, hormone replacement therapy and other types of hormone therapies like tamoxifen may cause vaginal bleeding after menopause as a side effect. If you're taking a medication that can lead to postmenopausal bleeding, your healthcare provider may perform other tests to rule out any other potential causes.

Infections

Sexually transmitted infections (STIs) and other infections of the cervix or uterine lining can cause the tissue to become inflamed. This can lead to postmenopausal bleeding. For infections caused by bacteria, medical providers typically prescribe oral antibiotics.

Bleeding from other areas

In some cases, bleeding that originates from other areas may be mistaken for spotting after menopause. Hemorrhoids, or swollen veins in the rectum or around the anus, can cause bright red bleeding when you have a bowel movement or wipe yourself after going to the bathroom. It’s possible to mistake the blood for vaginal bleeding.

Blood in the urine due to a urinary tract infection or kidney stones may also be confused with vaginal bleeding. Even if you suspect the blood may be coming from somewhere else, let your healthcare provider know about your symptoms since conditions such as urinary tract infections, kidney stones and severe hemorrhoids may require treatment.

Uterine polyps

Growths called polyps can develop along the inner wall of the uterus. The stalks of the polyps can irritate and inflame the surrounding tissue, leading to postmenopausal bleeding. Many uterine polyps are benign. However, the growths can become cancerous. As a result, healthcare providers may recommend surgery to remove uterine polyps that are causing vaginal bleeding after menopause. 

Endometrial hyperplasia

About 133 out of 100,000 women develop endometrial hyperplasia, a rare precancerous condition where the lining of the uterus gets thicker. One of the biggest risk factors for endometrial hyperplasia in menopausal women is having too much estrogen without enough progesterone. This causes the uterine lining to continue to grow and thicken. In menopause, the ovaries have stopped making estrogen. However, the excess fat cells in women who are obese can create a significant source of endogenous estrogen.

Diabetes, early menses, irregular menses and PCOS (polycystic ovary syndrome) are some additional risk factors for endometrial hyperplasia. People with endometrial hyperplasia may experience postmenopausal bleeding due to the changes in the uterine lining.

There are different levels of severity of endometrial hyperplasia.  Milder levels of hyperplasia may be treated with oral progestin therapy, a progestin IUD or hormonal injections. More severe cases of endometrial hyperplasia are treated with hysterectomy.

Cancer

Cancers of the uterus, vagina and cervix can all cause postmenopausal bleeding. However, cancer is the cause of only around 10% of cases of vaginal bleeding after menopause. If you're diagnosed with cancer, a specialist can create a treatment plan for you that may include surgery, radiation, chemotherapy and other interventions.

If you experience any bleeding or spotting after menopause, let your healthcare provider know as soon as possible. Even if you only see a small amount of blood or it happens just once, it’s better to get an evaluation from your provider than to wait and see. 

Your provider may perform a pelvic exam and order blood work, a pap smear and/or imaging tests as needed to determine the cause of postmenopausal bleeding. You may also need a minor in-office procedure called an endometrial biopsy or cervical biopsy.  Then, you can discuss treatment options to address vaginal bleeding after menopause.

Published April 2023.