What to Know About Postmenopausal Bleeding

Postmenopausal bleeding (PMB) can feel alarming—and it should never be ignored. If you’ve gone 12 months or more without a period, any spotting, staining, or bleeding is considered postmenopausal bleeding, even if it’s just one episode.

"One spot is one spot too many after menopause. It always deserves a closer look."

Here’s what you need to know about the causes, what evaluation involves, and why early attention is essential.

First, Know This: PMB Needs Evaluation

Any bleeding after menopause must be checked out. That’s because about 5% of women with PMB will be diagnosed with uterine (endometrial) cancer, though risk estimates range from 1% to 14%.

If you're using menopause hormone therapy (MHT), especially in the first year of continuous estrogen-progestogen treatment, spotting can occur—but it’s still not safe to assume it's harmless. Bleeding of any kind deserves evaluation.

"Postmenopausal bleeding is cancer until proven otherwise."

What Can Cause Postmenopausal Bleeding?

Hearing that any bleeding after menopause needs to be checked for cancer can feel overwhelming—but it’s important to know that most cases of postmenopausal bleeding are not caused by cancer.

One of the most frequent causes is endometrial atrophy—this simply means the lining of the uterus has become very thin and fragile after menopause, making it more prone to bleeding.

Another common culprit is a polyp, a small non-cancerous growth inside the uterus or cervix that can cause unexpected bleeding. Fibroids, which are benign muscle growths in the uterus, may also play a role, though they’re less common after menopause.

In some cases, the uterine lining grows too much, a condition called endometrial hyperplasia. This isn’t cancer, but in certain forms, it can become cancer over time, so it’s something your provider will take seriously. Medications—especially hormone therapies—can also lead to bleeding. If you’ve recently started or changed hormone treatment, that could be part of the picture. Vaginal atrophy (thinning and dryness of the vaginal tissues) can sometimes cause bleeding or spotting, especially after intercourse or pelvic exams. And occasionally, the bleeding isn’t from the uterus at all—it could come from the bladder, rectum, or even hemorrhoids.

"Benign causes are common—but distinguishing them from something more serious is crucial."

What Increases Your Risk of Uterine Cancer?

Although many cases of postmenopausal bleeding are harmless, there are certain factors that raise the risk of endometrial (uterine) cancer—and being aware of them can help guide decisions about testing and follow-up. Obesity is one of the most significant risk factors. That’s because fat tissue produces estrogen, and higher levels of unopposed estrogen (estrogen not balanced by progesterone) can stimulate the uterine lining. Diabetes and PCOS (Polycystic Ovary Syndrome) are also linked to higher estrogen levels and may contribute to a greater risk over time. A family history of endometrial or colon cancer—especially if there's a known condition like Lynch syndrome—can increase inherited risk. If this is in your family tree, it’s worth sharing with your provider. Women who have never been pregnant or who experienced late menopause (meaning more lifetime exposure to estrogen) also have slightly higher risk. And of course, simply getting older plays a role, as most cases of endometrial cancer are diagnosed after menopause. Finally, taking estrogen without progesterone—called unopposed estrogen—will increase risk if you still have your uterus. This is why hormone therapy is carefully tailored and monitored.

"Even if you don’t have classic risk factors, bleeding after menopause should always be taken seriously."

Some aggressive forms of cancer (Type II) can occur in women without traditional risk factors. This type is more common in Black women, who may also have fibroids that complicate imaging.

How Is Postmenopausal Bleeding Evaluated?

When you report bleeding after menopause, your provider will likely order a few simple tests to help figure out what’s going on.

1. Pelvic Ultrasound

This is usually the first step. A small probe is placed in the vagina to take pictures of the uterus and measure the thickness of the lining (called the endometrial stripe).

2. Uterine Lining Sample (Endometrial Biopsy)

Your provider may take a small sample of the tissue from inside the uterus. This can often be done right in the office and only takes a few minutes.

A normal result is usually reassuring, but if the bleeding continues, additional tests may be needed. Sometimes, cancer can be missed if the abnormal cells are only in one area.

3. Closer Look at the Uterus

If the ultrasound images aren’t clear—because of fibroids, body size, or the shape of the uterus—other tools help get a better view:

• A sonohysterogram uses saline (salt water) to open up the uterus for clearer ultrasound images.

• A hysteroscopy uses a tiny camera to look directly inside the uterus.

These tests help find polyps, growths, or anything unusual that might not show up on a basic ultrasound.

4. Blood Tests

Your provider might check for things like low iron or signs of anemia, thyroid issues, or hormone imbalances (specifically an imbalance between estrogen and progestorone such that the uterus isn't adequately protected.) These tests help get a fuller picture of your health and rule out other causes of bleeding.

What If a Thick Endometrial Lining Is Found by Chance?

Sometimes a thickened lining is found in a postmenopausal woman who has no bleeding—maybe during imaging for pelvic pain or another issue.

• Routine biopsy isn’t always necessary.

• Risk factors and symptoms guide whether further testing is needed.

"A number is not a diagnosis. Evaluation should match your personal risk profile."

What Happens If Hyperplasia or Cancer Is Found?

• Cancer or complex atypical hyperplasia: You’ll be referred to a gynecologic oncologist.

• Simple hyperplasia: This can often be treated with progestin therapy (oral or IUD-based) and monitored closely.

  

  "Endometrial changes can often be reversed—if they’re caught early.

Final Word

• Any bleeding after menopause warrants evaluation.

• Ultrasound and/or biopsy are the main tools used.

• Risk factors matter—but cancer can occur without them.

• Persistent or late-onset bleeding on MHT is not “normal.”

"Bleeding after menopause is never just a nuisance. It’s a sign that something needs a closer look."

Don’t delay or downplay symptoms. Most of the time, postmenopausal bleeding is due to something benign—but when it isn’t, early diagnosis can be life-saving.

If you’ve had any bleeding, spotting, or staining after menopause—even once—call your healthcare provider. You deserve answers and reassurance.