Bleeding after menopause

What counts as bleeding after menopause?

Menopause is the date of your final period, and you can only know it in hindsight. The American College of Obstetricians and Gynecologists (ACOG) defines it as no periods for 1 year, and the NHS says it is usually diagnosed in women over 45 who have not had a period for more than a year. Bleeding after that point is called postmenopausal bleeding.

So the date that matters is the first day of your last period. Count 12 months from there. If you bleed 13 months later, that is bleeding after menopause, however much it looks like a period coming back. Bleeding at month 10 or 11 still falls inside perimenopause, where skipped periods followed by a late one are common, and our guide to irregular periods in perimenopause covers those gaps.

Two situations blur the count. Hormonal contraception such as the hormonal coil, the implant or the progestogen-only pill can stop periods altogether, so you may not know when your natural last period was. And some hormone therapy is given in a way that brings a monthly bleed. In both cases, tell the doctor about any bleeding you are unsure of and let them decide which side of the line it is on.

Spotting after menopause: does a small amount count?

Yes. The NHS tells you to see a GP about bleeding after menopause "even if it's only a small amount or it's only happened once". That covers a pink streak on toilet paper, a brown mark in your underwear and a single day of light bleeding that never returns. ACOG lists bleeding after menopause among the bleeding that is not normal and says it is especially important to tell your doctor about it.

It is easy to explain a spot away, particularly if it came after sex or after a day of heavy lifting. The guidance makes no exception for either. Bleeding after sex is on ACOG's abnormal list at any age, which our page on spotting between periods explains for the years before menopause.

Bleeding a year after your last period: what can cause it

ACOG and the NHS list largely the same causes. The NHS names the first three as the most common:

• Thinning of the vaginal lining (atrophic vaginitis) or of the womb lining (endometrial atrophy), caused by lower oestrogen after menopause. A thin lining is more fragile and can bleed.
• Polyps in the cervix or the womb, growths that are usually not cancer. ACOG notes that polyps on the cervix can bleed after sex.
• A thickened womb lining (endometrial hyperplasia). It is not cancer, but both bodies say it can lead to womb cancer. The NHS links it to hormone replacement therapy, high oestrogen levels and being overweight.
• Hormone therapy itself, some other medicines and infections of the womb or cervix, which ACOG also lists.
• Less commonly, cancer: womb (endometrial) cancer, and more rarely other cancers such as ovarian cancer.

How likely is it to be cancer?

Most of the time it is not. A 2018 review in JAMA Internal Medicine pooled 129 studies covering more than 34,000 women with postmenopausal bleeding and found that about 9% of them had endometrial cancer. The figure ran from about 5% in the North American studies to 13% in the Western European ones. Roughly nine women in ten who bleed after menopause do not have cancer.

The same review looked at it from the other side: about 91% of women with endometrial cancer had postmenopausal bleeding. ACOG calls bleeding the most common sign of endometrial cancer after menopause and says that when it is diagnosed early, most cases can be treated successfully. That pairing is why the rule has no exceptions. Bleeding is usually harmless, and it is also the one early warning this cancer tends to give.

ACOG's risk factors for endometrial cancer include getting older, an early first period, a late menopause, never having been pregnant, obesity, PCOS, diabetes, high blood pressure, thyroid disease, the breast cancer drug tamoxifen, smoking and a personal or family history of certain cancers. It adds that the cancer can also occur in women with none of them, so having no risk factors is not a reason to wait.

Bleeding after 12 months with no period: how soon to go

The NHS treats it as non-urgent but not something to sit on: book a normal GP appointment. It also says a GP should refer you to a hospital or a postmenopausal bleeding clinic, and that you should not have to wait more than 2 weeks to see a specialist. If you are in the UK and your referral is taking longer, it is reasonable to call the surgery and ask.

Heavy bleeding is a different matter. Soaking a pad every hour for more than 2 hours, especially with chest pain, breathlessness or dizziness, is the emergency rule ACOG gives for heavy bleeding at any age, and it needs help the same day. The bleeding checker compares your answers with that rule and the others on this page.

Tests you may be offered

ACOG says your doctor should start with your personal and family health history, and you may have a physical exam. After that, the NHS lists what a specialist, who may be a nurse, is likely to offer:

• A vaginal ultrasound scan, where a small probe placed in the vagina shows the womb and measures how thick its lining is.
• An examination of the pelvis and vagina, often with a speculum so the cervix can be seen, and pressing on the tummy to feel for lumps, tenderness or swelling.
• A hysteroscopy, where a thin camera passes through the cervix to look inside the womb, usually with a small tissue sample (biopsy) taken at the same time, under local or general anaesthetic.

ACOG also describes an endometrial biopsy done through a thin tube, sonohysterography (an ultrasound with fluid in the womb to see the lining more clearly) and a dilation and curettage (D&C). Some of these happen in a clinic room on the same day, others in a hospital. Ask which one you are booked for and whether you need someone to take you home afterwards.

What comes next depends entirely on the cause, from no treatment at all to removing a polyp or surgery. That decision belongs with your specialist, and Peri Signals does not give treatment advice.

What to tell the doctor

A short written note makes the appointment faster. I would put these on it:

• the date of your last period, as close as you can get it, and how you know
• each day you have bled since, and how heavy it was: spotting, light, medium or heavy
• the colour, and whether it followed sex, a smear test or straining
• any pain, discharge, bloating or change in your pee or bowels
• every medicine you take, including hormone therapy, vaginal oestrogen, tamoxifen and blood thinners

Our printable symptom diary and appointment checklist has a space for each day's bleeding and a list of questions to take in.

My take

I would book the appointment the day you notice the blood, and I would not wait to see whether it happens again. One spot counts as fully as a heavy bleed in the guidance, and the referral rules exist to make the wait short. Go in expecting a harmless answer, because nine times out of ten that is what the evidence points to, and treat the scan as the way to get it confirmed.

Related reading

The guides to bleeding before menopause, from heavy periods and clots to bleeding for weeks, are collected under periods and bleeding. If you are not sure whether your periods have stopped for good, when perimenopause starts and how long it lasts explains the stages.