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My patient “Rosa” has come to my office for an appointment, but it’s not for her annual visit. Instead, she’s here for vaginal bleeding that has taken her by surprise. Rosa is a woman in her mid-60s who’s well past menopause.

Most women who experience bleeding after menopause are understandably concerned. After all, they thought they were done with it. (Menopause is officially confirmed if it has been 1 year since your last menstrual period.)

Rosa asks, “What could it be?”

Getting to the bottom of it

Postmenopausal bleeding can range from light spotting that is pinkish-gray or brown, all the way to a heavy flow, like a regular period. Most of the time, there is no pain with the bleeding. No matter your exact symptoms, you’ll want to get in touch with your ob-gyn right away if this happens to you.

Any evaluation should start with a detailed conversation, either in person or via telehealth (a phone call or video chat). Your ob-gyn should ask questions such as:

  • When did you go through menopause? The longer it’s been, the greater cause for concern and the more testing we might need to do.
  • Are you taking any new medications? Some drugs, such as blood thinners and some mental health medications, can have vaginal bleeding as a side effect.
  • What else is going on with your health? Other medical conditions could be relevant.

A pelvic exam usually is needed when we’re talking about unexplained vaginal bleeding. During the exam, your ob-gyn may look at your vagina and cervix and feel the size of your uterus.

The next steps will depend on your age, how long it has been since you reached menopause, and how much bleeding you’re experiencing. Your ob-gyn might suggest a pelvic ultrasound to look at your uterus more closely or a biopsy to take a tissue sample from the lining of your uterus. You might even need both.

Some cases call for a more complex procedure called a diagnostic hysteroscopy with dilation and curettage (D&C). In this procedure, your ob-gyn will place a camera into the vagina, through the cervix, and into your uterus. Cells are removed from the lining of your uterus. This tissue sample is sent to a lab for testing.

Causes and treatments

One reason for postmenopausal bleeding could be that the tissue of your vagina and vulva has gotten thinner. This can happen during menopause due to hormone changes. If you experience the bleeding after sex, it may be from friction against this thinner, more sensitive skin—but your ob-gyn still should do a full evaluation to be sure.

Topical estrogen cream often resolves this kind of postmenopausal bleeding. Using lubrication during intercourse can help as well. If the lining of your uterus is super-thin, your ob-gyn might consider hormone therapy in the form of pills or an intrauterine device (IUD).

Polyps also can cause vaginal bleeding. If your ob-gyn discovers these benign (noncancerous) growths in your uterus or on your cervix, you might need surgery to remove them.

Another possibility: You could be bleeding because the lining of your uterus is becoming too thick. In some cases, the cells of the lining can become abnormal, leading to cancer.

Cancer is the most serious, but also least likely, cause of bleeding after menopause. If testing finds cancerous cells or cell changes that could lead to cancer, your ob-gyn should refer you to a specialist called a gynecologic oncologist.

Even if it isn’t cancer, you may need future ultrasounds to keep an eye on things. If you find the bleeding or follow-up tests to be very bothersome, and other treatments haven’t worked, talk with your ob-gyn. In some cases, you could consider a hysterectomy to remove your uterus. You and your ob-gyn can discuss what might be right for you.

Rosa’s plan

After performing a pelvic exam and an ultrasound, I could tell that Rosa’s uterine lining was thicker than it should be at her age. Obesity and diabetes put her at high risk for endometrial cancer, so I recommended we collect some tissue for testing. After discussing the options, Rosa chose to have a D&C and a hysteroscopy. Thankfully, Rosa’s test results showed no evidence of cancer.

But Rosa wasn’t out of the woods. Her bleeding returned about 3 years later, kicking off the process all over again. She has been clear that she wants to avoid a hysterectomy. As long as she keeps coming to see me every time she has bleeding, we’ll stick to this approach—keeping an eye on her with pelvic exams, ultrasounds, and other tests as needed. It’s a plan that is both safe and aligned with her wishes.

Act now, not later

Bleeding after menopause is not normal, so take it seriously. Go directly to your ob-gyn. Chances are, there’s no reason for panic. But only through careful evaluation can we be sure what we’re dealing with.

Published: October 2020

Last reviewed: October 2020

Copyright 2020 by the American College of Obstetricians and Gynecologists. Read copyright and permissions information.

This information is designed as an educational aid to patients and sets forth current information and opinions related to women’s health. It is not intended as a statement of the standard of care, nor does it comprise all proper treatments or methods of care. It is not a substitute for a treating clinician’s independent professional judgment. Read ACOG’s complete disclaimer.

About the Author
Tamika C. Auguste, MD
Dr. Tamika C. Auguste

Dr. Auguste is an obstetrician–gynecologist at MedStar Washington Hospital Center in Washington, DC, where she serves as Vice-Chair of Women’s and Infants’ Services, among other leadership roles. She is a professor at Georgetown University School of Medicine and a member of the American College of Obstetricians and Gynecologists’ Executive Board.