Erratic spotting and bleeding can continue for years during
perimenopause. Once you haven’t had a period for 12 consecutive months — the clinical definition of the end of the menopausal transition — you may feel relief that this era is finally in the rearview mirror.
That can make it all the more disconcerting when bleeding suddenly returns.
“This is a common complaint, affecting at least 10 percent of postmenopausal women,” says the obstetrician-gynecologist Mary Rosser, MD, PhD, an assistant professor and the director of integrated women's health at Columbia University’s Irving Medical Center in New York City.
Postmenopausal bleeding should be evaluated by a healthcare provider to determine the cause, but it’s not always related to a serious health problem.
Learn more about why you may experience bleeding during
postmenopause — whether it’s light pink spotting or dark brown discharge — and how it can be addressed.
The reasons behind irregular bleeding can range from easily addressed issues to more serious medical problems.
Endometrial and Vaginal Atrophy
Atrophy refers to a decrease in the size of cells, tissues, or organs, and it can happen in both the uterus and vagina. When the walls of either of these organs become thinner or the
vagina becomes drier, that can lead to microtears that are prone to light bleeding.
Research suggests the genital, urological, and sexual effects of
vaginal atrophy impact more than half of postmenopausal women.
“This is the most common cause of postmenopausal bleeding,” says Dr. Rosser.
Beyond unwanted bleeding, tears to the vagina can also cause
painful sex, which can impact the quality of your sexual relationships.
Treatment for endometrial and vaginal atrophy often involves hormonal therapies, like estrogen patches, creams, rings, or tablets. Nonhormonal therapies for those who can’t tolerate estrogen can include vaginal lubricants or moisturizers.
Fibroids
Fibroids, which are noncancerous tumors that form inside or on the uterine wall, can cause heavy bleeding and may also be associated with postmenopausal bleeding. But it’s not common for fibroids to be the source of the problem for older women.
“Fibroids typically regress after menopause due to decreased estrogen,” says Rosser. “When fibroids are present in postmenopausal women, they may manifest as abnormal uterine bleeding.” She says this is particularly true of submucosal fibroids, which are the type that grows under the inner lining of your uterus.
According to Tangela Anderson Tull, MD, a menopause specialist with Hoffman and Associates, an all-female obstetrics and gynecology practice affiliated with Mercy Medical Center in Baltimore, some women who have fibroids may have postmenopausal bleeding, “but the more likely scenario is that perimenopause is not yet completely over.”
Endometrial Hyperplasia
Unlike atrophy, where the uterine lining or vaginal walls become thinner,
endometrial hyperplasia is characterized by a thickening of the lining of the uterus, often caused by an imbalance of estrogen and progesterone
. A known cause of irregular bleeding, it’s most frequently seen in women in their fifties and sixties who have already gone through menopause.
Common risk factors for this condition include: having started your period at an early age, never having been pregnant,
obesity,
polycystic ovary syndrome (PCOS), and having taken the breast cancer medication tamoxifen. There are also links to
diabetes and thyroid disease.
If left untreated, endometrial hyperplasia may develop into
uterine cancer.
Progestin therapy may be recommended as a treatment for women who have abnormal but not cancerous cells. For those whose cells are precancerous, a
hysterectomy may be the appropriate course of treatment.
Menopausal Hormone Therapy
Postmenopausal women are often prescribed hormone therapy to help manage unwelcome symptoms such as
hot flashes that can continue even after your period has ended. But while this treatment can provide relief for overheating, it also can bring on unwelcome side effects.
“Hormone therapy may cause breakthrough bleeding in some women,” says Rosser.
Bleeding while taking hormone therapy typically stops after the first six months, and it isn’t usually a cause for concern. But if it continues beyond that time frame or the bleeding becomes heavier, you should check in with your healthcare provider.
Uterine Polyps
Uterine polyps are benign growths on the inner lining of the uterus, also known as the endometrium. They extend into the uterine cavity and can cause irregular bleeding in both perimenopausal and postmenopausal women.
“Postmenopausal polyps with bleeding warrant removal to rule out malignancy, though the overall risk is low,” says Rosser.
Treatments for endometrial polyps often include hormone therapy to improve bleeding symptoms, surgery to remove the polyps, or, in rare cases, a hysterectomy.
Endometrial or Cervical Cancer
Uterine cancer, also known as endometrial cancer, most commonly occurs after menopause, and roughly 90 percent of patients diagnosed with endometrial cancer report postmenopausal vaginal bleeding.
But that doesn’t mean that 90 percent of people who have later-life bleeding issues will develop cancer.
“Research shows that only around 10 percent of women who have postmenopausal bleeding have endometrial cancer, with most cases due to benign conditions such as polyps, genitourinary syndrome of menopause, or bleeding in women using hormone therapy,” says Rosser.
But the probability of endometrial cancer as the cause of postmenopausal bleeding increases with age, she adds. Cervical cancer, on the other hand, is more common in women in their thirties.
Beyond the irregular bleeding, another sign of endometrial cancer includes pain in the pelvic area.
Endometrial cancer is usually first treated with surgery to remove the uterus, fallopian tubes, and ovaries.
The risk factors for postmenopausal vaginal bleeding often depend on the cause, says Stephanie Faubion, MD, the director of the Mayo Clinic Center for Women’s Health in Jacksonville, Florida, and the medical director of the Menopause Society.
Anyone can have vaginal bleeding after menopause, but it may also be related to these risk factors:
- Smoking
- Obesity
- Diabetes or thyroid disease
- Polycystic ovary syndrome
- Reaching menopause after the average age of 51
The American College of Obstetricians and Gynecologists (ACOG) emphasizes that postmenopausal bleeding requires prompt and efficient medical evaluation, regardless of how much blood is present or how long it’s been going on.
Tull says you can start by seeing a primary care provider, but if they don’t practice gynecological care, you can also make an appointment with a family medicine physician, midwife, or an ob-gyn. While it’s never easy to face the possibility of a cancer diagnosis, she says it’s better to treat health problems sooner rather than later.
“With postmenopausal bleeding, I would go get it checked out even if it’s just one episode,” says Tull.
You should expect a comprehensive exam to determine the cause of the postmenopausal bleeding. This will likely include the following:
- Pelvic exam, to check the vagina and cervix
- Pap smear, to test for irregular cervical cells
- Transvaginal ultrasound, to view your pelvic organs
- Endometrial biopsy, to collect cells from your uterine lining
“If I see a patient in the office and she has bleeding, we usually do an ultrasound first,” says Tull. Your provider may also ask you questions about when your period ended, which prescription drugs you’re taking, and if you have any underlying health conditions.
If persistent or recurrent bleeding occurs despite initial negative findings, further testing such as hysteroscopy with dilation and curettage may be warranted, says Rosser.
Rachel Green
Rachel Davis
Derek Schulz
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Dr. Amara Okafor