Bleeding or spotting after the menopause

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) – which can be caused by hormone replacement therapy (HRT), high levels of oestrogen or by being overweight; if left untreated this can lead to development of womb cancer (also known as endometrial cancer)

About 1 in every 10 women with post-menopausal bleeding will have womb cancer, and in a few cases bleeding may be a sign of another type of cancer such as vulval, vaginal or 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 camera test called 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, which may be a nurse, will take your medical history and record your symptoms. You'll 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 biopsy or hysteroscopy. This is mainly determined by the thickness of the womb lining.

Pelvic examination

The specialist will also carry out a pelvic examination. They will insert a 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 overdue.

If the lining of the womb is thickened, a small sample of tissue (biopsy) may be removed using a fine, flexible plastic tube. This can cause cramps and bleeding, which usually settles very quickly. The test can be stopped if you are finding it too uncomfortable, so let the healthcare professional carrying out the test know if you want them to stop.

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 either local anaesthetic (where the area is numbed so you don't feel any pain) or general anaesthetic (where you are asleep).

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. 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, although treatment may not be necessary if your symptoms are minimal.

There are various types of endometrial hyperplasia which may be treated with hormone medication (tablets or an intrauterine system implant) or surgery to remove your uterus, cervix and ovaries (a total hysterectomy). Occasionally, if the changes are mild, no treatment may be necessary.

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, a total hysterectomy will often be recommended.