Bleeding after menopause: causes, red flags and why it must be checked

After menopause, oestrogen falls and the lining of the womb and vagina thins. This thin tissue can bleed easily. However, the womb lining can also thicken abnormally from excess oestrogen, from polyps, or from cancer, all of which cause bleeding as well. Because the symptoms overlap, bleeding is always investigated.

• Atrophic vaginitis or endometrial atrophy: thinning of tissues, with dryness, soreness and light spotting.

• Endometrial polyps: benign growths in the womb lining.

• Hormone replacement therapy, especially sequential regimens, with expected withdrawal bleeds or breakthrough bleeding.

• Endometrial hyperplasia: thickening of the lining, which can be a precursor to cancer.

• Cervical polyps, cervical ectropion and infections.

• Fibroids, and medicines such as tamoxifen and anticoagulants.

• Endometrial (womb) cancer, which is the main cancer to exclude, and cervical or vaginal cancer.

• Bleeding from the urethra, bladder or bowel, mistaken for vaginal bleeding.

Bleeding that recurs or increases, bleeding with pelvic pain or pressure, watery or bloody discharge, bleeding in women on tamoxifen, obesity, diabetes, high blood pressure, a history of PCOS or no children, and unexplained weight loss are risk factors that heighten concern.

• Call 999 or go to A&E: heavy bleeding with dizziness, fainting or severe pain.

• Urgent GP: any postmenopausal bleeding, including spotting, even if it stopped, and should be referred under the suspected cancer pathway.

• GP within days: bleeding on HRT that is unexpected or persistent after the first few months.

• Do not wait to see if it returns.

The doctor asks when your last period was, how heavy and how often bleeding occurs, HRT or tamoxifen use, pain, discharge, weight, and medical history. They perform an abdominal and pelvic examination and may take swabs or a smear if due.

• Transvaginal ultrasound: measures the thickness of the womb lining, a key first test.

• Hysteroscopy with biopsy: a camera look inside the womb with a tissue sample, often done in clinic.

• Endometrial biopsy: samples the lining for abnormal cells.

• Blood tests: full blood count and, if indicated, other tests.

• MRI scan: if cancer is diagnosed, to assess spread.

Do not delay seeking help because the bleeding was light or stopped. Make a note of dates and amounts. Vaginal moisturisers or oestrogen can help dryness once serious causes are excluded. If you take HRT, discuss unexpected bleeding with your prescriber promptly.

The NHS route is a GP and urgent gynaecology referral, often a one-stop clinic. Private gynaecology can arrange ultrasound and hysteroscopy quickly, but should not delay an urgent NHS pathway.