If you’ve gone through menopause, you shouldn’t have any menstrual bleeding as menopause means you haven’t had a period in at least one year.

BUT if you have any bleeding — even if it’s only spotting — you should see a doctor because there may be a number of causes, some of them serious such as cancer.

What causes it?

A number of conditions may lead to postmenopausal bleeding:

Polyps: These tissue growths show up inside your uterus or cervical canal, or on your cervix. They’re usually not cancer, but they can cause spotting, heavy bleeding, or bleeding after sex.

Endometrial atrophy (thinning of the uterine lining): The endometrium is the tissue that lines your uterus. It responds to hormones like oestrogen and progesterone. 

Low hormone levels after menopause can cause it to get too thin. This may trigger bleeding.

Endometrial hyperplasia (thickening of the uterine lining): After menopause, you may have too much oestrogen and too little progesterone. As a result, the endometrium gets thicker and can bleed. 

Sometimes cells in the endometrium can become abnormal and this could lead to cancer, so get it treated as soon as possible.

Vaginal atrophy (thinning of vaginal tissue): Oestrogen helps to keep this tissue healthy but after menopause, low levels can cause your vaginal walls to become thin, dry, and inflamed. 

That often leads to bleeding after sex.

Cancer: Bleeding is the most common symptom of endometrial or uterine cancer after menopause. It can also signal vaginal or cervical cancer.

Sexually transmitted diseases: Some, like chlamydia and gonorrhoea, may cause spotting and bleeding after sex. Herpes sores can also bleed.

Medication: Bleeding is often a side effect of certain drugs, like hormone therapy, tamoxifen, and blood thinners.

How is It diagnosed?

To find the cause of your bleeding, the doctor will do a physical exam and review your medical history. 

You may need an ultrasound or endometrial biopsy, or a D&C to get a sample of the uterus lining. They send this to a lab that will check for polyps, cancer, or a thickening of the uterine lining (endometrial hyperplasia).

What is the treatment?

That will depend on what’s causing the bleeding, but generally this will involve some form of oestrogen from a tablet used orally or vaginally, or a cream or gel or vaginally with a cream or ring. 

Or you may be prescribed a form of progestin – the synthetic version of progesterone – in the pill or coil. 

If you have polyps or thickened parts of the uterine lining caused by endometrial hyperplasia. This is a Hysteroscopy where a doctor will insert a narrow telescope into your vagina and pass tiny surgical tools through the tube.

Other surgical options may include a D&C (dilation and curettage) which opens your cervix  remove polyps or thickened areas of the uterine lining caused by endometrial hyperplasia. 

Sometimes a hysterectomy may be suggested to remove part or all of your uterus and used for endometrial or cervical cancer. Some women with a precancerous form of endometrial hyperplasia may also need it and in some cases the ovaries, fallopian tubes, or nearby lymph nodes may also be removed.

Medications like antibiotics may be given for sexually transmitted diseases and can also treat cervical or uterine infections.

Helpful information

 It cannot be stressed enough that any bleeding post menopause needs to be investigated as a precaution – no matter how trivial it may seem.

Bioidentical options for synthetic oestrogen and progestins are available and without the associated side effects.

Good hormone balance is essential post menopause as the levels of both oestrogen and progesterone drop, but progesterone drops further and faster.

You need both hormones for helping reduce the risk of osteoporosis and to help with vaginal dryness, but it is progesterone that reduces the risk of hormonal cancers.

You may find the following article helpful on hormones and cancer risk:

https://anna.blog.wellsprings-health.com/bioidentical-hormones-cancer/