What Causes Postmenopausal Bleeding? Here Are 10 Causes to Watch For

Menopause starts 1 year after the last menstrual cycle. This typically happens between the ages of 40 and 58, with the menstrual cycle ending after age 50 for most women. Any vaginal bleeding that occurs more than 1 year after the menopause is abnormal and is known as “postmenopausal bleeding.” 

Postmenopausal bleeding isn’t always due to something serious. But whether it’s light or heavy, you should always visit your healthcare provider to find the cause. Let’s take a look at the 10 most common reasons you may have bleeding after menopause. 

1. Vaginal or endometrial atrophy

The most common cause of postmenopausal bleeding is vaginal or endometrial atrophy. This condition is caused by lack of estrogen to the vagina and lining of the uterus. When estrogen levels drop due to menopause, these areas can become thin and then bleed. This may be more likely to happen after local trauma or sex.  

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Other symptoms of vaginal atrophy may include:

• Vaginal discomfort

• Chronic vaginal itching

• Vaginal dryness

• Frequent urination

2. Uterine fibroids

Fibroids are benign (noncancerous) growths in the muscle of the uterus. Fibroids typically shrink when the ovaries stop making estrogen in menopause. 

But some people who have a heavier body weight continue to make some estrogen in their fat cells. Sometimes this triggers fibroid growth and bleeding after menopause. 

3. Adenomyosis

Adenomyosis is when the lining of the uterus gets embedded in the muscle layer of the uterus.  This can cause the uterus to get bigger and painful and lead to abnormal bleeding — especially when you still have a monthly menstrual cycle. 

Adenomyosis usually is not active in menopause. But if you happen to have a heavier body weight, or have taken breast cancer treatment (like Tamoxifen), you may have excess estrogen. And this may be a source of abnormal bleeding after menopause.  

4. Endometrial polyps

Endometrial polyps are fleshy growths that can occur in the lining of the uterus. And they’re a common cause of bleeding after menopause. It’s not clear why some people develop polyps and others don’t.

Endometrial polyps are usually benign. But they should be biopsied or surgically removed because they can sometimes be precancerous or cancerous. Endometrial polyps can be removed with a simple outpatient procedure (hysteroscopy). 

5. Endometrial intraepithelial neoplasia

Endometrial intraepithelial neoplasia (EIN) is a precancerous change in the lining of the uterus. There are three types of EIN — ranging from mild to severe. But, if caught early enough, even severe EIN can be treated.

Most people with EIN who are postmenopausal are given the option to remove the uterus (hysterectomy). When EIN is treated with medications instead of surgery, there’s a life-long risk of developing endometrial cancer. That makes hysterectomy the preferred treatment for people with bleeding after menopause caused by EIN. 

6. Cervicitis

Cervical infections can cause inflammation of the cervix and bleeding after menopause. This can occur with sexually transmitted infections (STIs), like:

• Gonorrhea

• Chlamydia 

• Trichomonas   

Postmenopausal bleeding due to cervicitis is more likely to happen after sex.

7. Cervical cancer

Some people develop bleeding after menopause due to cervical cancer. Pap smear screening is widely used to detect cervical cancer, and the overall rates have dropped a lot. 

If you have postmenopausal bleeding and it has been more than a year since you’ve had a normal pap test, talk with your provider about cervical screening. Cervical cancer is treatable when caught early.

8. Endometrial (uterine) cancer

One of the most serious causes of postmenopausal bleeding is endometrial cancer. About 9 in 10 people with endometrial cancer have bleeding after menopause. But the risk of cancer is still low. Only about 1 in 10 of women with postmenopausal bleeding have endometrial cancer. 

Risk factors for developing endometrial cancer include:

• A family history of endometrial cancer

• A BMI of 30 or higher

• Diabetes

• Hypertension

• Polycystic ovarian syndrome (PCOS)

Your provider will use transvaginal ultrasound and endometrial biopsy to make the diagnosis of endometrial cancer. Treatment generally uses hysterectomy, but it can also include chemotherapy or radiation therapy. 

9. Ovarian cancer

Sometimes ovarian cancer is the cause of bleeding after menopause. This more often happens with a specific type of ovarian cancer called a granulosa cell tumor. This type of tumor can make estrogen and cause postmenopausal bleeding in about half of people who have it.  

A pelvic ultrasound or MRI can tell if there’s a mass in the ovary and help make the diagnosis. People with a granulosa cell tumor will need a referral to a gynecologic oncologist (a cancer specialist in women’s health). 

10. Hormone replacement therapy

Hormone replacement therapy with estrogen can cause postmenopausal bleeding. This can happen from prescription estrogen to lessen menopause symptoms. But, in some cases, it can also happen from high dietary intake of plant estrogens (phytoestrogens).

Plant estrogens are most commonly found in products like:

• Tofu

• Soy milk

• Soybeans

• Flax

• Garlic

• Legumes

• Edamame

Dietary phytoestrogens rarely cause postmenopausal bleeding. But always talk with your provider if you have bleeding after menopause and suspect it may be related to estrogen you’re taking in.

Is vaginal bleeding after menopause normal?

Vaginal bleeding after menopause is not normal under any circumstances. The bleeding may be light spotting or heavy, like a menstrual cycle. But always visit your provider for a checkup so they can find the source of the bleeding and get you the proper care.

In postmenopause, abnormal bleeding most likely comes from the uterus or the vagina. But not all vaginal bleeding starts in the vagina. It can be hard to tell where the bleeding starts because it all exits through the vagina.  

Bleeding that looks like it’s coming from the vagina may actually be bleeding from the:

• Cervix

• Fallopian tubes

• Bladder or urinary tract

• Rectum

• Vulva (the skin around the vagina) 

What tests can find the cause of postmenopausal bleeding?

Your provider can find out what’s causing your vaginal bleeding after menopause with several different exams. First they’ll want to know more about the bleeding. They will likely ask you to describe how much bleeding you’re having and if you have any pain with it. You’ll then need a physical exam and other testing to find the source of your bleeding. 

Other exams or tests your provider may suggest are: 

• Speculum exam: The speculum goes inside the vagina so your provider can see the vagina and cervix. 

• Pap smear: The pap smear is a microscopic test for cervical cancer. This is especially helpful if you have a history of abnormal pap smears.  

• Cervical and vaginal cultures: A culture can be taken with a cotton swab from the cervix or vagina. These can be used to see if an infection is the source of bleeding.  

• Bimanual exam: Your provider can insert one hand in the vagina to feel the size and shape of your uterus. If you have fibroids, you may have an abnormally large uterus.  

• Pelvic ultrasound: This will show any abnormalities of the reproductive organs, including the uterus or ovaries. 

• Endometrial biopsy: This is a common in-office procedure to get tissue from the lining of the uterus using a thin tube.

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Written by:

Kimberly Turner, MD

Kimberly Turner, MD, is an OB/GYN physician who has been in clinical practice for over 30 years. She graduated from Duke University medical school and currently practices gynecology in the state of Maryland.

Edited by:

Karla Robinson, MD

Karla Robinson, MD, is a medical editor for GoodRx. She is a licensed, board-certified family physician with almost 20 years of experience in health through varied clinical, administrative, and educational roles.

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