What Causes Postmenopausal Bleeding? Here Are 10 Causes to Know About

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 get evaluated to find the cause. Let’s take a look at the 10 most common reasons for bleeding after menopause.

1. Vaginal or endometrial atrophy

One 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.

Other symptoms of vaginal atrophy may include:

• Vaginal discomfort

• Chronic vaginal itching

• Vaginal dryness

• Frequent urination

2. 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 (noncancerous). But they should be biopsied or surgically removed because they can sometimes be precancerous or cancerous. Your gynecologist can remove these polyps with a simple outpatient procedure (hysteroscopy). 

3. Uterine fibroids

Fibroids are benign 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.

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4. 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 isn’t 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.

5. 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   

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

6. Endometrial intraepithelial neoplasia

Endometrial intraepithelial neoplasia (EIN) is a precancerous change in the lining of the uterus. It’s also known as atypical endometrial hyperplasia. 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 have the option to undergo hysterectomy, or removal of the uterus. When EIN is treated with medications instead of surgery, there’s a lifelong risk of developing endometrial cancer. That makes hysterectomy the preferred treatment for people with bleeding after menopause caused by EIN.

7. Endometrial (uterine) cancer

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

Risk factors for developing endometrial cancer include:

• Postmenopausal age

• Body mass index (BMI) of 30 or higher

• Greater exposure to estrogen, including hormone treatment for breast cancer, early age of menstruation onset, and not having pregnancy

• Inherited disorder called Lynch syndrome

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

8. 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 it has been more than 3 years since you’ve had a normal Pap test, talk with your healthcare team about cervical screening. It’s important for everyone with a uterus to get screened, no matter what your age is. Treatment for cervical cancer is more successful when caught early.

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 therapy

Hormone therapy with estrogen, called menopausal hormone therapy (MHT), is commonly prescribed to lessen menopause symptoms. But it can sometimes cause postmenopausal bleeding. It may be more likely with oral (by mouth) therapy than transdermal (through the skin), and tends to lessen over time.

Rarely, high dietary intake of plant estrogens (phytoestrogens), like soy products, can also cause postmenopausal bleeding.

Is vaginal bleeding after menopause normal?

No. Vaginal bleeding after menopause isn’t normal. Whether it’s light spotting or heavy, like a menstrual cycle, always visit a healthcare professional for a checkup. They can find the source of the bleeding and get you the proper care, if needed.

What tests can find the cause of postmenopausal bleeding?

Your healthcare team can find out what’s causing bleeding after menopause with 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. They will also ask about your menstruation history, other medical conditions, and medications.

Other exams or tests may include:

• Physical exam: A physical examination can show any obvious sources of bleeding. 

• Speculum exam: The speculum goes inside your vagina and allows your gynecologist to see your 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 determine if an infection is the source of bleeding.  

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

• Transvaginal ultrasound: Experts recommend this imaging test to look at the thickness of the uterine lining, which can determine if a biopsy is needed.

• Endometrial biopsy: This is a tissue sample from the lining of the uterus, which will be sent to a lab for further testing.

• Hysteroscopy: In some cases, your gynecologist may recommend this procedure to get a better look inside the uterus. They will put a thin, lighted tube with a camera at the end through the cervix and into the uterus.

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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:

Sophie Vergnaud, MD

Sophie Vergnaud, MD, is the Senior Medical Director for GoodRx Health. A pulmonologist and hospitalist, she practiced and taught clinical medicine at hospitals in London for a decade before entering a career in health education and technology.

Reviewed by:

Mandy Armitage, MD

Mandy Armitage, MD, has combined clinical medicine with her passion for education and content development for many years. She served as medical director for the health technology companies HealthLoop (now Get Well) and Doximity.

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