Postmenopausal bleeding: causes and tests

The term applies to bleeding from the vagina once the menopause has happened. The NHS explains that menopause is usually diagnosed in women aged over 45 who have not had a period for more than a year. After that point, any red, pink or brown blood on tissue paper, underwear or in the toilet bowl counts, whether it is heavy or just a streak.

Bleeding that comes after a gap of a year or more without periods is different from the irregular bleeding of the perimenopause, when cycles are changing but have not stopped. The NHS says to see a GP even if the bleeding is light or has only happened once. People taking HRT may have planned bleeding depending on the regimen, so unexpected or persistent bleeding on HRT should still be raised with the prescriber.

There are several possible causes, and in most people the explanation is benign. The NHS lists the most common ones as inflammation and thinning of the vaginal lining (atrophic vaginitis) or womb lining (endometrial atrophy), both caused by lower oestrogen levels; polyps of the cervix or womb, which are usually non-cancerous; and a thickened womb lining, known as endometrial hyperplasia.

The NHS says hyperplasia can be caused by hormone replacement therapy (HRT), high oestrogen levels or being overweight, and that it can lead to womb cancer. Less commonly, the cause is cancer of the womb or ovary.

Because the symptom looks identical whatever the cause, it is not possible to judge by the amount of blood, how often it happens or whether there is pain. That is why the investigation is offered every time.

Cancer Research UK states that the most common symptom of womb cancer is abnormal bleeding from the vagina, especially in women who have stopped having periods. It also lists unusually heavy or persistent bleeding between periods and a pink, abnormal vaginal discharge among the symptoms.

Cancer Research UK stresses that most people with these symptoms do not have womb cancer. Even so, the NHS notes that cancer may be easier to treat if it is found early, which is the reason for fast referral. Being overweight or obese is described by Cancer Research UK as one of the biggest risk factors for womb cancer in the UK.

Less common signs of womb cancer, such as tummy pain, bloating, changes in bowel or bladder habits or a new cough, are also listed by Cancer Research UK, but bleeding is by far the main warning sign.

The GP will ask about the bleeding, when periods stopped, any HRT or other hormone treatment, medicines such as blood thinners, and other symptoms such as discharge or pain. They may examine the vulva, vagina and cervix.

The NHS says that a GP should refer you to hospital or to a special postmenopausal bleeding clinic and that you should not wait more than 2 weeks to see a specialist. Referral does not mean cancer has been found. It means that the quickest route to a clear answer is being used. Anyone who has not heard about an appointment within a couple of weeks should contact the GP surgery to ask where the referral has reached.

A specialist, who the NHS says may be a nurse, will offer tests to find out what is causing the bleeding and plan any necessary treatment. The tests may include several steps, and not everyone needs all of them.

• A vaginal ultrasound scan, in which a small device is placed in the vagina to look at the womb lining and ovaries.

• A pelvic examination, sometimes using a speculum to hold the vagina open so that the inside of the vagina and the cervix can be seen.

• Hysteroscopy, in which a thin telescope-like camera passes through the cervix into the womb, with a tissue sample (biopsy) taken for testing. It can be done under local or general anaesthetic.

• A manual check, with the specialist pressing on the tummy and inside the vagina to feel for lumps, tenderness or swelling.

The NHS sets out how each cause is handled. Cervical polyps may need to be removed by a specialist. Vaginal or endometrial atrophy may need no treatment, though oestrogen cream or pessaries may be offered. If bleeding is a side effect of HRT, the answer may be changing or stopping it.

Endometrial hyperplasia is managed according to its type. Options include no treatment, hormone medicine such as tablets or an intrauterine system (IUS), or a total hysterectomy. Where womb cancer is found, the NHS says a total hysterectomy will often be recommended, sometimes followed by radiotherapy, chemotherapy, hormone therapy or a combination. Ovarian cancer is treated with surgery to remove the ovaries and sometimes the womb, and may also involve chemotherapy.

After a benign cause has been treated, ask the clinic what to do if bleeding comes back, and who to contact. Recurrence should always lead to another assessment.

Waiting for tests can be worrying, particularly because the word cancer is so often mentioned. It may help to remember what the sources say: it is not usually serious, and most people with these symptoms do not have womb cancer. Writing down questions before the appointment, and bringing someone for support, can make the visit easier.

Hysteroscopy and biopsy can cause cramping similar to period pain, and light spotting for a short time afterwards is common. Ask the clinic about pain relief options before the day and whether you can eat and drink beforehand.

Results are usually explained at the same clinic or by letter. If a result is unclear or a second opinion is wanted, a GP can arrange a further review.

On the NHS the route begins with the GP and leads to a rapid-access gynaecology or postmenopausal bleeding clinic. Some people with private health insurance or who pay for themselves choose to see a gynaecologist privately, where ultrasound, hysteroscopy and biopsy may be offered in a single visit. Either way, it is sensible to ask how results will be shared with the GP.

Seek urgent medical help, through NHS 111 or A&E, if bleeding is very heavy, soaks through pads quickly, comes with dizziness or fainting, or is accompanied by severe pain. Call 999 if you collapse.