A woman no longer experiences menstrual periods once she enters menopause—the term for the natural decline in reproductive hormones a woman experiences in her 40s and 50s. After a year has passed without menstrual periods, any vaginal bleeding that that occurs is known as postmenopausal bleeding, and it is considered abnormal.

There are several possible causes of postmenopausal bleeding, most of which are not worrisome. However, between 10% and 15% women who experience postmenopausal bleeding may have endometrial cancer. For this reason, it’s important for women to see a doctor quickly for assessment after even one episode of postmenopausal bleeding.

A number of treatments are available that can address the causes of postmenopausal bleeding, from age-related tissue atrophy to cancer. Early treatment leads to the best outcomes, particularly for women who have cancer.

During a woman’s 40s, as she approaches menopause, hormone levels begin to change—the ovaries produce less estrogen during this time of life (known as perimenopause), and menstrual periods may become irregular and/or less frequent.

Once a woman has gone an entire year with no menstrual periods, she has entered menopause. (The average age of menopause among American women is 51.)

Postmenopausal bleeding refers to any vaginal bleeding that occurs in a menopausal woman. Because all postmenopausal bleeding is considered abnormal, it’s important to contact your provider if this occurs.

In some cases, this type of abnormal bleeding may be a sign of endometrial cancer, the most commonly diagnosed gynecological cancer. More than 90% of postmenopausal women with endometrial cancer experience vaginal bleeding (postmenopausal bleeding).

There are several causes of postmenopausal bleeding, including:

• Polyps, or growths that are usually benign (non-cancerous) on the cervix or uterine lining
• Fibroids (non-cancerous uterine growths)
• Atrophy, or thinning, of the vaginal and/or uterine lining
• Excessive thickening of the uterine lining
• Certain infections of the cervix or uterus
• Vaginal intercourse
• Sexual trauma
• Endometrial cancer
• Cervical cancer
• Ovarian cancer

Additionally, certain medications may cause postmenopausal bleeding, including hormone therapy and tamoxifen for breast cancer.

Any vaginal bleeding after menopause is considered to be postmenopausal bleeding. Different women can experience bleeding differently, however. Below are some of the ways this can happen:

• Any small amount of blood
• Bleeding that seems to mimic a menstrual period
• Blood clots that pass with other bleeding
• Heavier flow than what a woman experienced during menstrual periods
• Blood that appears after vaginal intercourse
• Blood that appears on toilet paper after using the bathroom
• Pink vaginal discharge
• Brown vaginal discharge

Some women with postmenopausal bleeding may also experience:

• Abdominal pain
• Fever
• Chills
• Headache
• Dizziness
• Changes in bladder and/or bowel function

It’s important to note that blood flow does not need to be heavy for a woman to seek guidance from her doctor. Even a single instance of questionable postmenopausal bleeding is worth discussing with a provider. (It’s important to note that many women, particularly early in the postmenopausal time frame, will have a very late period, but the provider should rule out the abnormal potential causes before assuming that is the explanation.)

Women who have reached menopause may be at increased risk of postmenopausal bleeding if they:

• Have a history of uterine or cervical polyps

• Have fibroids

• Take hormone therapy

• Take tamoxifen

• Experience vaginal dryness

• Experience sexual trauma

Women with a personal or family history of these conditions may also be at increased risk:

• Obesity

• Diabetes

• Breast cancer

• Endometrial cancer

• Colon cancer

When a woman experiences postmenopausal bleeding, doctors should be able to diagnose the cause of her bleeding after obtaining a medical history, performing a physical exam, and running diagnostic tests.

To learn about a postmenopausal woman’s personal health history, doctors may ask whether she takes hormone therapy or tamoxifen, if she has had breast cancer, and if she has a history of fibroids or polyps. Doctors may also ask about her history of menstrual periods: When they began, when they ended, how long they typically lasted, and how heavy the blood flow was. They may also ask about birth control methods used prior to menopause.

During a pelvic exam, the doctor will look for internal sores or areas that may indicate that bleeding has occurred, as well as areas that are painful or tender to the touch. If no source of bleeding is found, doctors may investigate whether the bleeding originated within the urinary tract or digestive system.

The following tests may be used to provide information that leads to a diagnosis:

• Transvaginal ultrasound, which doctors use to see whether the endometrium (uterine lining) is thicker or thinner than normal.
• Hysteroscopy, during which a long, thin tube with a camera on its end is inserted into the uterus through the vagina to look for/check for signs of abnormal bleeding
• Endometrial biopsy, during which a small sample of the uterine lining is removed and studied under a microscope to look for signs of cancer.
• Cervical biopsy, a procedure used to check for signs of cancer if any lesions or abnormal areas are discovered on the cervix.

Treatment of postmenopausal bleeding is based on its cause.

• Vaginal atrophy: Doctors may prescribe vaginal lubricants, topical hormones, or other medications to reduce vaginal dryness.
• Polyps or fibroids. If polyps or fibroids are the source of postmenopausal bleeding, surgery may be recommended to remove them.
• Hormone therapy. If the bleeding occurs because of hormone therapy, doctors may modify or suspend therapy.
• Infection. If an infection is identified, medications will be prescribed to eliminate the infection and stop future bleeding.
• Thick uterine lining. If postmenopausal bleeding happens because a woman has a thick uterine lining (endometrial hyperplasia), progestin therapy may be prescribed to trigger shedding of the uterine lining. Sometimes, doctors may remove the uterine lining surgically, during a dilation and curettage (D&C) procedure.
• Endometrial cancer. If a woman is diagnosed with endometrial cancer, surgical removal of the uterus (hysterectomy), often along with the ovaries and fallopian tubes, may be needed. Local lymph nodes may also be biopsied to see if the cancer has spread. A woman may receive chemotherapy or radiation after surgery, depending on the circumstances of her diagnosis.

Women who experience postmenopausal bleeding usually have positive outcomes. Medication and other treatment options should help to stop bleeding among women whose symptoms are due to non-cancerous causes.

If a woman experiences postmenopausal bleeding because of endometrial cancer, early detection and treatment will help to improve the outcome. When endometrial cancer is discovered before it spreads, 95% of women survive 5 or more years. When the cancer has spread to nearby parts of the body, the 5-year survival rate drops to 69%. Once the cancer spreads to distant areas of the body, only 18% survive 5 or more years.

“No matter what the cause of the bleeding, Yale has excellent doctors to take care of it,” says Mary Jane Minkin, MD, a Yale Medicine gynecologist with a special interest in menopause. “If you have fibroids or polyps, our gynecological endocrinology and minimally invasive surgery doctors are quite skilled at removing any abnormal tissue that needs to be removed, or prescribe hormonal therapies to resolve the problem. If you have a gynecological cancer, we have an outstanding section of gynecological oncology surgeons with equally skilled specialized gynecological radiation therapists to provide any necessary follow-up care.”

And you can see our oncology surgeons in many hospitals, extending from Greenwich up to New London, she adds.

“You will have Yale quality providers close to home. And Yale also offers, as part of the section of gynecological oncology, a clinic specializing in sexuality, intimacy, and menopause for cancer survivors,” says Dr. Minkin. “And of course, all of our gynecological oncologists participate in National Institutes of Health-sponsored clinical trials to bring our patients the latest in research.”