When you experience a menstrual cycle, light spotting is not usually considered unusual or an automatic cause for concern. If it’s accompanied by other symptoms, it’s definitely worth seeking medical advice. But for many, it’s a regular part of their cycle.
After menopause, the perception of any bleeding changes dramatically. Any vaginal bleeding after menopause is considered abnormal and should be investigated.
Postmenopausal Bleeding: An Overview
During perimenopause (the stage before menopause), your menstrual cycles and periods gradually come to an end. The average length of perimenopause is four years and, during that time, your period can become irregular and there can be irregular bleeding between periods.
Just as periods maybe started out irregularly when you went through the changes of puberty, so they become irregular as you go through the changes of perimenopause and menopause.
Because of this gradual change, many individuals are unsure when perimenopause ends and menopause begins. In medical terms, menopause is confirmed 12 months after your last period.
Bleeding after this point is called post-menopausal bleeding (PMB) and it is considered abnormal bleeding.
Don’t Panic. But Do See a Doctor…
If you Google "vaginal bleeding after menopause", the search results are likely to send you into a panic.
Please don’t panic! There are many explanations for spotting after menopause. And despite what Dr. Google says, it does not automatically mean you have cancer.
According to this study published by JAMA Internal Medicine, “postmenopausal bleeding occurs in approximately 90% of women with endometrial cancer; however, only 9% of women with postmenopausal bleeding were diagnosed with endometrial cancer.”
So, why the urgency to see a doctor?
Well, endometrial cancer cannot be screened for, which means it can go undetected if symptoms are ignored.
So, even though postmenopausal bleeding can occur for a variety of reasons, understanding that it can allow for early detection of endometrial cancer means it’s always worth investigation.
Causes of Spotting Post-Menopause
As mentioned, postmenopausal bleeding is caused by many things. You may also experience different colors of spotting too, including brown spotting. While we urge you to work with your doctor to determine the underlying cause, it might be helpful to know some of the most common explanations:
You’re Still in Perimenopause
One obvious reason you might experience spotting after menopause is that you’re not yet actually in menopause. The perimenopause stage lasts on average four years. But for some women this stage may last only a few months or continue for 10 years.
Considering periods become irregular at this stage, it can be easy to mistake the stage you’re in for menopause. It’s worth tracking your periods and irregular bleeding so you and your doctor can understand what stage you’re in.
If you’ve gone 12 months since your last period, you’re considered in menopause.
Vaginal Atrophy (Thinning Tissue in the Vagina)
Vaginal or endometrial atrophy occurs in some women after menopause. The body produces less estrogen after menopause, which can lead to the thinning, drying and inflammation of the vaginal walls.
According to the Mayo Clinic, “Because the condition causes both vaginal and urinary symptoms, doctors use the term "genitourinary syndrome of menopause (GSM)" to describe vaginal atrophy and its accompanying symptoms.” You may also notice brown spotting or other bleeding.
In addition to bleeding, symptoms of GSM include:
- Vaginal dryness, burning and itching
- A burning sensation when urinating
- Frequent urinary tract infections (UTIs)
- Urinary incontinence
- Decreased vaginal lubrication during sex and increased discomfort during sex
Endometrial Atrophy or Endometrial Hyperplasia
The endometrium is tissue that lines your uterus. Fluctuating or irregular hormone levels during menopause can affect this tissue in two possible ways:
- Thinning of the Endometrium (Atrophy): According to the American College of Obstetricians and Gynaecologists, low estrogen levels can cause the tissue of the endometrium (or uterine lining) to thin, which can result in some bleeding.
- Thickening of the Endometrium (Hyperplasia): The uterine lining becomes thickened, most often due to increased estrogen and decreased progesterone. This condition can sometimes lead to cancer, though it may be prevented if detected early (source). Early indicators include unusual bleeding.
Polyps are usually benign, noncancerous growths in the uterus, cervical canal, or on your cervix. While they are not usually harmful, they can grow quite large, which can cause discomfort. Women with polyps can experience bleeding.
Sexually Transmitted Diseases (STIs) and other infections like Pelvic Inflammatory Disease (PID) can all be explanations of spotting.
Most infections are treatable. But infections can become more serious if ignored, so it’s worth getting routinely tested for STIs.
While exercise is essential for good all-round health, strenuous exercise after menopause can cause some bleeding (or perhaps brown spotting). Generally, this is not something to be concerned about. But if it happens for the first time, it’s good to seek reassurance from your doctor.
Hormone Replacement Therapy (HRT)
Hormone Replacement Therapy is a form of hormone therapy used to treat symptoms associated with female menopause, including:
- Hot flashes
- Vaginal atrophy
- Accelerated skin aging
- Vaginal dryness
- Bone loss
These symptoms are related to decreased levels of sex hormones that occur during menopause. HRT medications are available in different formulations, including oral tablets and capsules and patches, gels and creams.
Side effects of HRT medications include unusual bleeding, though this is considered a less common side effect. More information about HRT can be found on the Mayo Clinic.
In addition to HRT, a side effect of other medications can include unusual bleeding. For example blood thinners may cause unusual postmenopausal spotting.
If you are on any medications you think might cause spotting, discuss this side effect with your doctor. She will help you determine if there’s any additional risk.
Cervical or Uterine Cancer
According to the Dana-Farber Cancer Institute, spotting in post-menopausal women can, in some cases, be an early sign of cancer and should always be investigated further.
“Any post-menopausal bleeding should warrant a visit to a gynecologist,” says Ursula Matulonis, MD, chief of the Division of Gynecologic Oncology at Dana-Farber Cancer Institute.
Time to See a Doctor? What to Expect…
In general, any bleeding post-menopause is worth a trip to your health care provider. Even if the spotting is minor, it’s worth eliminating the (slight) risk that it could be an early indicator of cancer.
It’s worth noting that age is a factor too. According to the American Cancer Society, endometrial cancer most often affects postmenopausal women — 60 is the average age at diagnosis.
But don’t take this caution as a reason to panic. Odds are, there’s another explanation for your bleeding. And your health care provider may be able to help you address the symptoms.
So, what can you expect when you see your doctor?
To diagnose and treat any cause of abnormal perimenopausal bleeding or bleeding after menopause, your doctor will:
- Review your personal and family health history
- Perform a physical exam, which may include the following tests
- Endometrial biopsy
- Pelvic ultrasound
- Dilation and curettage (D&C)
Some of these tests can be performed by your doctor. For others, your doctor may refer you to a hospital or surgical center.
Treatment of Post Menopausal Bleeding
Your treatment could include hormone therapy, which could be administered through pills, creams or patches.
Or it could involve other procedures, like:
- Hysteroscopy: During hysteroscopy, instruments inserted through the hysteroscope (a device your doctor uses to see inside your uterus) can be used to remove polyps.
- D&C (dilation and curettage): A surgery in which your cervix is opened (or dilated). Your doctor will then use a surgical instrument called a curette to remove uterine tissue.
- Hysterectomy: This is a major surgery to remove part or all of the uterus. Your doctor may also recommend the removal of your ovaries, fallopian tubes, cervix or nearby lymph nodes at the same time.
It’s important to understand that post-menopausal bleeding or spotting is never considered normal. You should see your health care provider if this is happening to you. However, please don’t panic or jump to the worst possible conclusions. As we’ve seen, these symptoms can have many possible causes and not all are considered serious.