Postmenopausal bleeding

The menopause is considered complete once a full year has passed without a single period. From that point the womb lining no longer sheds, and any blood coming from the genital tract falls outside what is normal. This is not only about heavy bleeding: light spotting, pinkish or brown discharge, a mark on underwear or on the paper after using the toilet all belong in the same group.

The rule to start with

Any bleeding after the menopause deserves to be investigated. Even if it happened only once. Even if the amount was tiny. Even if nothing else is wrong.

The rule does not mean something terrible has happened. It means something else: you cannot tell a harmless cause from a dangerous one by looking — not from the amount of blood, not from its colour, not from how well you feel. A woman with a polyp and a woman with early cancer of the womb lining see exactly the same mark on their underwear. What separates them is not the symptom but the examination.

So the phrase "it is probably nothing serious" belongs after the examination and the scan, not instead of them. There is also no need to wait for a second episode to be sure: the second one may be months away, and here time is expensive. A single stain and a heavy bleed lead to exactly the same action — book an appointment.

What counts as bleeding

It is worth being seen if, after a year without periods, you notice:

• blood in any quantity, from heavy to a single drop;
• spotting, or pink, rusty or brown discharge;
• traces of blood after sex or after straining;
• blood-stained discharge with an unpleasant smell;
• anything you cannot say for certain is blood or not.

If your periods stopped less than a year ago the situation is different: during the transition the cycle becomes erratic, the gaps get longer and bleeding can be irregular. Even then there are limits — bleeding that is very heavy, that lasts longer than you are used to, or that returns after several quiet months is still worth discussing.

Separately, learn the signs that call for same-day help or an ambulance rather than a booked appointment: blood soaking a pad within an hour and doing so repeatedly, severe weakness, dizziness, pallor, a racing heart, or sudden pain low in the abdomen. The single European emergency number is 112.

Why there is a hurry

There is one specific reason for the hurry: cancer of the womb lining, also called endometrial cancer. After the menopause it is the most common gynaecological cancer, and in almost everyone affected its first and for a long time only sign is bleeding. Pain, weight loss and a general sense of illness usually come much later, if at all.

That is where the whole rule comes from. This cancer has a property that is rare in oncology: it announces itself early, with a signal that is easy to notice, at a stage when treatment usually works and often means surgery alone. Investigating the very first episode is therefore not overcaution — it is precisely how the disease gets caught while it is curable.

That said, in most women who come in with postmenopausal bleeding the cause turns out to be benign rather than cancer. That is good news, but it changes nothing about the order of events: the only way to learn which group you are in is to be examined, and being examined does not take long.

The commonest cause: a thinned lining

Most often the blood comes from atrophy. After the menopause oestrogen levels fall, the lining of the vagina and of the womb cavity becomes thin, dry and fragile, and its small blood vessels sit almost at the surface. Friction, sex, straining or dry air is enough to produce a drop of blood.

Other signs usually keep it company: dryness, burning, discomfort during sex and sometimes a need to pass urine more often or with stinging, because the tissues of the urethra change in the same way. Atrophy itself is not dangerous and responds well to treatment — usually local oestrogen as a cream or pessary, plus non-hormonal vaginal moisturisers.

One caveat matters. Atrophy is the commonest answer, but it is the last one to be given, once everything else has been ruled out. Treating "the dryness" without looking at the womb lining is not safe: atrophy and a tumour coexist happily in the same body and produce identical spotting.

Polyps, a thickened lining, hormones and tamoxifen

Several other causes turn up regularly:

• Polyps of the cervix or the womb cavity — soft outgrowths of the lining. Almost always benign, they bleed easily, are usually removed, and are always sent for analysis.
• Endometrial hyperplasia — an excessive thickening of the womb lining. Some of its forms are regarded as pre-cancerous, so seeing the thickening on a scan is not enough: a piece of tissue has to be taken to find out which type it is. It is encouraged by excess weight, diabetes, a late menopause and taking oestrogen without protection for the lining.
• Menopausal hormone therapy. Breakthrough bleeding is possible in the first months and after a change of regimen. That is expected, but it is still discussed with a doctor rather than blamed on the treatment on your own.
• Tamoxifen. It is prescribed after breast cancer and it stimulates the womb lining: polyps form more often during treatment, the lining thickens, and the risk of womb cancer is higher. Any bleeding in a woman taking tamoxifen is investigated without delay. At the same time the drug is never stopped on your own initiative — that decision belongs to the cancer specialist.

Less often the cause is infection or inflammation of the lining, injury, blood-thinning medicines, or a clotting disorder.

The blood does not always come from the womb

A stain on underwear does not name its own source. Blood can come from the cervix, because of inflammation, a polyp or occasionally cervical cancer. It can come from a thinned vaginal wall. It can be blood in the urine from a bladder infection, a stone or kidney disease. It can come from the back passage, from piles or a fissure, and be honestly mistaken for vaginal bleeding.

None of this cancels the appointment; it only changes where the doctor looks. A good part of the answer comes from the examination itself, and after that a urine test or another specialist's opinion is added if needed.

There is also a common misunderstanding: "I had a smear test recently, so everything must be fine." Cervical screening looks at the cervix and is no substitute at all for examining the womb cavity. A normal screening result does not remove the need to investigate bleeding.

How the cause is found

The work-up is usually short and fits into one or two visits.

• Examination. The external genitals and the cervix are inspected using a speculum, and the womb and ovaries are felt through the abdomen. This step alone shows a bleeding cervical polyp, inflammation or an injury, and swabs are taken if needed.
• Ultrasound scan. Usually transvaginal, with the probe inside the vagina, because the view is better. The key measurement is the thickness of the womb lining: a thin, even lining makes a tumour very unlikely, while a thickened or irregular one means going further. The ovaries are looked at in the same session.
• Endometrial biopsy. A thin tube is used to take a sample of the lining for analysis. It is often done in the clinic room without anaesthetic; the sensation is like a period cramp and it does not last long.
• Hysteroscopy. A slim camera is passed into the womb cavity so it can be seen from the inside, with tissue taken from the right spot or a polyp removed. It is done under local or general anaesthetic, usually without an overnight stay.

What follows depends on the finding. Atrophy usually needs no more than local treatment. A polyp is removed. Hyperplasia is managed with monitoring, hormone treatment or surgery, depending on what the microscope shows. For endometrial cancer the mainstay is surgery, with radiotherapy or drug treatment added when indicated. Which medicines and what doses is decided by the treating doctor and cannot be settled from a distance.

Online consultation

An online appointment is a quick way to work out what to do next instead of losing a week thinking about it. The doctor will ask when your last period was, what the discharge looked like, whether it followed sex, what medicines you take — hormone therapy, tamoxifen and blood thinners in particular — and whether there are any bladder or bowel symptoms alongside it.

From that, they can tell you which tests apply in your case, help you read a scan or report you already have, explain what a biopsy involves, and say plainly if your situation needs a face-to-face examination today rather than in a few days. What an online consultation cannot do is replace the examination and the scan: postmenopausal bleeding always ends in an in-person assessment.

This material is for information only and does not replace medical advice.