Post-menopausal bleeding is vaginal bleeding that happens at least 12 months after your periods have stopped.

Although it’s a common problem, it’s not normal to bleed at this time – even if it’s just spotting – so don’t ignore it. Make an appointment to see your GP as soon as possible.

The cause is usually something minor, such as inflammation of the womb lining, 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 womb lining (endometrial atrophy) – caused by lower oestrogen levels
• cervical or womb polyps – growths, which are usually non-cancerous, that can form in the cervix (neck of the womb) or the womb itself
• a thickened womb lining (endometrial hyperplasia) – caused by hormone replacement therapy (HRT)
• abnormalities of the cervix or the womb

About 1 in every 10 women with post-menopausal bleeding will have womb cancer (also known as endometrial cancer). In some cases, bleeding may be a sign of another type of cancer, such as cervical cancer.

Diagnosing the cause

Your GP should refer you to hospital for further tests. This will help to identify the cause of your problem, to exclude cancer and plan necessary treatment. Some areas have specialist post-menopausal bleeding clinics. 

The tests that may be carried out can include:

• a vaginal ultrasound scan
• a pelvic examination
• tests on a sample of your womb lining (endometrial biopsy)
• a hysteroscopy

These procedures are described below. Some GPs are able to carry out the ultrasound and examination 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 will then go to the scan room for an examination.

Vaginal ultrasound scan

A vaginal ultrasound scan is performed by gently inserting a fine ultrasound probe into your vagina, which you may find slightly uncomfortable. It usually takes about 10 minutes.

The probe emits high-frequency sound waves to create an image of the inside of your vagina and womb, which is then displayed on a monitor.

The results of this examination will then be discussed with you, and you’ll find out whether you need a hysteroscopy.

Pelvic examination

The specialist will also carry out a pelvic examination. They will insert a plastic speculum into your vagina, similar to having a cervical screening test, so your vulva, vagina and cervix can be carefully examined. Most women find this a bit uncomfortable.

Swabs may be taken from your vagina and/or cervix to rule out any infection. The doctor may wish to carry out a cervical screening test as well 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. This is 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 performed for women who have had an abnormal cervical screening test result.

The speculum is then removed and an internal 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.

Hysteroscopy

A hysteroscopy allows the doctor to look inside your womb and remove a small sample of tissue for testing using a fine telescope-like instrument called a hysteroscope.

The hysteroscope is passed through your cervix under local anaesthetic (where the area is numbed so you don’t feel any pain), although occasionally it may be done under general anaesthetic (where you are asleep).

Read more about having a hysteroscopy.

Treating post-menopausal bleeding

Treatment depends on what is causing your bleeding.

For example, 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. 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 your bleeding is thought to be a side effect of HRT, altering or stopping the treatment may be recommended.

If you have womb cancer, surgery to remove your uterus and cervix (called a total hysterectomy) will often be recommended. 

Read more about treating womb cancer.

The Map of Medicine is used by doctors throughout the NHS to determine the best treatment options for their patients. NHS Choices offers everyone in England exclusive and free access to this cutting-edge internet resource, which lets you see exactly what your doctor sees.

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Map of Medicine: abnormal vaginal bleeding