Bleeding after menopause

No. Any bleeding from the vagina 12 months or more after your last period, even a small amount or a single episode, needs a doctor's check. Most causes are benign, such as a thin vaginal lining or polyps, but bleeding can also be the first sign of uterine cancer.

The most common causes are thinning and inflammation of the vaginal lining (atrophic vaginitis) or the uterine lining (endometrial atrophy), caused by low estrogen. Polyps and a thickened uterine lining are the next most common. Cancer is less common: about 9% of women with postmenopausal bleeding have endometrial cancer.

About 9% in a review of 129 studies, ranging from 5% in North American studies to 13% in Western European ones. That means most women who bleed don't have cancer, but bleeding is present in 91% of endometrial cancers, so checking every episode catches most cancers early.

No. Once you've gone 12 months without a period, any bleeding isn't a period and needs checking. The 12-month rule exists because periods can restart after several months without bleeding, especially under 50. If you're on sequential HRT, the monthly withdrawal bleed is expected and isn't a true period.

Usually because low estrogen has made the vaginal lining thin and fragile, so it tears easily during sex. Cervical polyps are another common cause. Less often, bleeding after sex is a sign of cervical cancer, so it should always be checked. Vaginal estrogen and lubricant usually help when atrophy is the cause.

Spotting is investigated the same way as heavier bleeding, because the amount of bleeding doesn't tell you the cause. Even a single episode of light spotting 12 months after your last period needs a doctor's check. It's usually caused by something benign, like atrophy or a polyp.

Before your periods stop, heavy or irregular bleeding is common, but excessive bleeding that affects your life, or bleeding between periods or after sex, still needs a doctor. Breakthrough bleeding on HRT is common in the first 4 to 6 months of continuous combined HRT. Once you're 12 months past your last period, any bleeding needs checking.

Cramping doesn't tell you the cause. Pain in the lower back, pelvis or lower abdomen with unusual bleeding can be a symptom of cervical cancer, but it has many benign causes too. After a biopsy, some cramping and light bleeding are normal. Either way, any bleeding after menopause needs checking.

Usually with a transvaginal ultrasound to measure the uterine lining and an exam of the vagina and cervix. If the lining is over 4 mm, can't be measured clearly, or bleeding keeps returning, the next step is a biopsy of the lining or a hysteroscopy, where a thin camera looks inside the uterus.

Some bleeding is expected. On sequential HRT you'll have a monthly withdrawal bleed. On continuous combined HRT, irregular spotting is common in the first 4 to 6 months. See your doctor if bleeding lasts beyond 6 months, gets heavier, or starts after you'd stopped bleeding.

It's checked the same way whether it happens 1 year or 20 years after your last period. The risk of endometrial cancer rises with age, so bleeding later in life deserves the same prompt attention, not less. Atrophy remains a very common cause at any age after menopause.

In ICD-10-CM, postmenopausal bleeding is coded N95.0. Related codes include N95.2 for postmenopausal atrophic vaginitis and N95.1 for menopausal and female climacteric states. Codes are used for medical records and insurance claims; they don't change how the bleeding is investigated.