Menopause is the time that marks the end of your menstrual cycles – defined officially as when you haven’t had a period for a full 12 months.1 Given that a woman will have around 450 periods during her lifetime, which equates to 3,500 days spent bleeding2 , it can be a huge relief not to have to worry about them anymore. It can be an even greater consolation if you might have experienced increasingly worse, irregular, more frequent and heavy periods in the perimenopausal years leading up to the menopause.
That said, however, some women do experience bleeding or spotting (very light vaginal bleeding) again after their periods seem to have stopped for good. In fact, an estimated 10% of women over 55 experience postmenopausal bleeding (PMB).3 So just when you think that’s the end of your menstruating days as you have known them suddenly you are bleeding again - so what’s going on and why?
One thing that can confuse matters is that while the average age women go through the menopause in the UK is 514 the timing of this transitional stage can be complicated by the fact that you may be using a hormonal contraceptive up until the recommended age of 55, and this may have already stopped your periods. This can then make it harder to pinpoint exactly if, and when, your menopause has happened.
The point is, bleeding after menopause may or may not be a cause for concern but it can be potentially disconcerting so what are the reasons for it and when should you be worried?
Why you might experience postmenopausal bleeding
There are many reasons why postmenopausal bleeding can happen including:
Fibroids or uterine (or endometrial) polyps.
These are generally benign growths that develop in or around the womb (uterus) which are stimulated by oestrogen. They can cause bleeding when starting HRT or due to spikes in natural oestrogen levels.5 An ultrasound or a procedure known as a hysteroscopy may be recommended to examine the womb to diagnose fibroids and/or polyps.6
HRT
Hormone replacement therapy (HRT) is not guaranteed to make you bleed-free. Bleeding can typically occur when changing the type or dosage of your HRT prescription, if you miss a dose, your patches keep falling off or you have a skin reaction that may affect how much oestrogen you are absorbing through your skin. You are also more likely to have a bleed with a sequential HRT regimen rather than a continuous one.
Vaginal/urogenital changes.
Vaginal dryness and soreness may lead to bleeding. Vaginal atrophy – thinning and drying out of the vaginal walls – affects around one in three women after menopause as a result of decreased oestrogen. It can also cause pain and/or bleeding during and after sex.7 Consultant Gynaecologist Anne Henderson explains more about other vaginal changes you can expect during menopause here.
Cervical changes
This is an important factor to consider if you are overdue for a smear (if you are under 50 you should have one every three years and if you are over 50 you will be invited every five years up to the age of 65),8 have had an abnormal test in the past and/or are bleeding after intercourse.
Endometrial changes
In rare cases, bleeding after menopause can be a sign of endometrial cancer.9 9700 women in the UK will be diagnosed with each year, is the fourth most common cancer in women10 and it is estimated that 90% of women diagnosed with it experience bleeding11 . Age is the biggest factor however – with most women being over 70 at the time of diagnosis.
What to do if you start bleeding after menopause
The reasons for postmenopausal bleeding are generally straightforward and treatable but it should always be taken seriously.
Track any changes.
Keep a log of your bleeds – even if they seem insignificant and light -using the free Health and Her Menopause. Build up as full a picture as you can – not only when you bleed but also the kind of bleeding you experience – for instance, is it light or heavy? Is it bright red in colour or more dark brown in appearance? Is the blood ‘watery’ and thin or thicker in texture? Recording all this can help to establish if there is any kind of pattern to your bleeding and/or will help to give your GP or specialist a more accurate record of what is happening to you and what your bleeding could mean.
Get it checked out.
It is vitally important if you have any unexplained or concerning bleeding that you discuss this with your GP who can review any medication you are on, examine you and suggest further examinations if necessary. You should do this even if it has only happened once, there’s only a tiny amount of blood and/or you don’t have any other symptoms. Your GP might refer you to hospital or to a special menopause bleeding clinic. The NHS say you should not wait more than two weeks to see a specialist.12 Treatment will depend on what is causing the bleeding.
References:
- https://thebms.org.uk/wp-content/uploads/2023/08/17-BMS-TfC-What-is-the-menopause-AUGUST2023-A.pdf
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2244694/
- https://my.clevelandclinic.org/health/diseases/21549-postmenopausal-bleeding
- https://journals.sagepub.com/doi/10.1177/0004563217706381?icid=int.sj-full-text.similar-articles.4
- https://www.nhs.uk/conditions/fibroids/#:~:text=After%20the%20menopause%2C%20they'll,available%20to%20help%20shrink%20fibroids.
- https://www.nhs.uk/conditions/hysteroscopy/
- https://www.londonwomenscentre.co.uk/info/news/postmenopausal-bleeding-faqs
- https://www.nhs.uk/conditions/cervical-screening/when-youll-be-invited/
- https://www.nhs.uk/conditions/womb-cancer/
- https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/uterine-cancer#:~:text=There%20are%20around%209%2C700%20new,UK%20(2016%2D2018).
- https://www.health.harvard.edu/womens-health/postmenopausal-bleeding-dont-worry-but-do-call-your-doctor
- https://www.nhs.uk/conditions/post-menopausal-bleeding/#:~:text=If%20you%20have%20postmenopausal%20bleeding,weeks%20to%20see%20a%20specialist
