Post-menopausal bleeding is vaginal bleeding that happens at least 12 months after your periods have stopped.
It is not normal to bleed at this time, even if it is just spotting, so don't ignore it. If you are still bleeding a year or more after your menopause, make an appointment to see your doctor as soon as possible.
The cause is usually something minor, such as inflammation of the womb lining (see below), but cancer is always a possibility that must be ruled out.
Most likely causes
There can be several reasons for bleeding after the menopause. The most common causes are:
- inflammation and thinning of the vaginal lining (atrophic vaginitis) or thinning of the womb lining (endometrial atrophy) caused by lower oestrogen levels
- cervical or womb polyps – these growths, which are usually non-cancerous, can form in the cervix (neck of the womb) or womb
- a thickened womb lining (endometrial hyperplasia) caused by hormone replacement therapy
- abnormalities of the cervix or the womb
Diagnosing the cause
Your doctor should refer you to a post-menopausal bleeding clinic for tests. The purpose of the clinic is to identify the cause of your problem, to exclude cancer and plan the necessary treatment.
Tests may include:
These procedures are described below. Some doctors are able to carry out the ultrasound and biopsy themselves, and will refer you for the hysteroscopy if this is necessary.
At the clinic
The specialist at the clinic will take your medical history and record your symptoms. You'll then go to the scan room for an examination.
Vaginal ultrasound scan
A vaginal ultrasound is performed by gently inserting a scan probe into your vagina, which you may find slightly uncomfortable. It takes about 10 minutes.
It uses high frequency sound waves to create an image of the inside of your vagina and womb.
The results of this examination will then be discussed with you, and you'll find out whether you need further investigations (a hysteroscopy) or whether you can be discharged.
The specialist will also carry out a physical examination. They will insert a metal speculum into your vagina, as if you were having a smear. Most women find this a bit uncomfortable. Your vulva, vagina and cervix will be examined carefully.
Swabs may be taken from your vagina and/or cervix to rule out any infection. The doctor may wish to carry out a cervical smear if this is due or if the cervix looks unhealthy.
Rarely, special stains may be applied to your cervix to make unhealthy tissue stand out, so a sample of this tissue can be extracted (biopsied) to be able to make a diagnosis. A magnifying instrument called a colposcope may be used to examine the cervix. This is the same examination peformed for women who have had an abnormal cervical screening test result.
The speculum is then removed and an internal pelvic examination is performed. This allows the doctor to gauge the size, shape and consistency of your womb, and also assess if there is any tenderness in your pelvis.
You and your doctor will be informed of the results of any swab, smear or biopsy within four weeks.
If you need a hysteroscopy, the doctor will try to perform this within the following two weeks.
A hysteroscopy allows the doctor to look inside your womb using a fine telescope called a hysteroscope (see the illustration on this page). The hysteroscope is passed through your cervix under local anaesthetic. You can watch the procedure on a TV screen if you wish.
Read more about having a hysteroscopy.
Treating post-menopausal bleeding
Treatment depends on what is causing your bleeding. If the cause is cervical polyps, you may need to have them removed. This fairly simple procedure can be done in the specialist's office using a local anaesthetic (the area is numbed so you don't feel any pain). Small forceps are used to grasp and gently twist the polyp, which usually comes off easily, and any bleeding is stopped using cautery (heat) or by applying chemicals.
Endometrial atrophy can be treated with oestrogen cream or pessaries, and endometrial hyperplasia is usually treated with hormonal medication (progestogens) and/or surgery to remove thickened areas of the womb lining.
If you have endometrial cancer, you will need surgery to remove your uterus and cervix (called a total hysterectomy). Read more about having a hysterectomy, treating uterine cancer and treating cervical cancer.