It was a single streak of pink on the toilet paper. She was 58, nine years past her last period, and she decided she must have scratched herself. She very nearly didn't mention it.
When she did, her GP referred her the same week. The scan showed a thin womb lining, and the bleeding turned out to come from dry, fragile vaginal tissue. Nothing sinister. Her GP was still right to move quickly, and she was right to speak up. Of all the changes women notice after menopause, bleeding is the one that should never be left to see if it settles, even though it usually turns out to be harmless.
You reach menopause once you have gone 12 months without a period. Any bleeding from the vagina after that point is called postmenopausal bleeding. It does not matter how small it is.
That includes:
Many women talk themselves out of it because it was tiny, or because it stopped, or because they assume their periods have simply restarted. Periods do not restart after a full year without them. If you are not sure whether you had reached menopause, because your periods were erratic for a long time, mention that too; your GP can still decide what to do.
Most bleeding after menopause has a harmless cause. But womb cancer, also called endometrial cancer, is the most common gynaecological cancer in the UK, and bleeding is how it usually shows itself.
The best evidence comes from a large review led by Megan Clarke at the US National Cancer Institute, which pooled 129 studies and more than 40,000 women. It found that about nine in ten women with womb cancer had postmenopausal bleeding, and that about one in eleven women with postmenopausal bleeding turned out to have womb cancer. The figure varied by region, from around 5% in North American studies to 13% in Western European ones.
Put those two numbers side by side. Most women who bleed don't have cancer. But almost all women who do have womb cancer bleed, and they often bleed early, when it's very treatable. Few cancers give such a clear early signal, which is exactly why it's worth acting on.
The common causes, roughly in order of how often they are found, are:
Bleeding can also come from somewhere that is not the womb at all, such as the bladder or the back passage. It is not always easy to tell where blood has come from, so let the doctor work it out.
In the UK, NICE advises GPs to refer women aged 55 and over with postmenopausal bleeding on the urgent suspected cancer pathway. In England, that pathway aims to give you a diagnosis, or rule cancer out, within 28 days. For women under 55, GPs should consider the same referral. Being referred this way is about speed. It doesn't mean your doctor thinks you have cancer.
At the clinic, the usual steps are:
A biopsy can be uncomfortable, sometimes painful. It is reasonable to ask about pain relief beforehand, such as taking ibuprofen an hour before if it is safe for you, and to ask whether a local anaesthetic is available.
HRT changes the rules, because some bleeding is part of how it works.
On sequential HRT, where you take a progestogen for part of each month, a regular monthly bleed is expected. What needs checking is a change: bleeding at the wrong time in the cycle, heavier or longer bleeds than usual, or bleeding after sex.
On continuous combined HRT, where you take oestrogen and progestogen every day, the aim is no bleeding. Irregular spotting is common for the first few months while the womb lining settles. Bleeding that carries on beyond about six months, or starts after you have had a spell with no bleeding at all, needs to be checked.
Sometimes the cause is simply that the progestogen dose is too low for the oestrogen dose. Your prescriber can review that, but they should not assume it without checking. Choosing the progestogen in your HRT explains why the balance matters, and HRT side effects covers the bleeding patterns in more detail.
Womb cancer is driven largely by oestrogen acting on the womb lining without enough progesterone to balance it. Risk is higher with:
None of these means you will develop it. But if any apply, they are a reason to report bleeding even sooner.
Do not wait for it to happen again. One episode is enough.
Do not rely on cervical screening. A smear test looks for HPV and cell changes in the cervix. It does not check the womb and will not pick up womb cancer.
Do not stop HRT on your own to see whether the bleeding stops. Tell your prescriber, who will decide whether you need a scan first.
Is a small amount of spotting after menopause normal?
No. It's common, but it isn't normal. Any bleeding 12 months or more after your last period should be checked, however light, even if it happens only once. It is usually harmless, but it needs to be confirmed.
What is the most common cause of bleeding after menopause?
Thinning and dryness of the vaginal and womb tissues because of low oestrogen. Polyps and HRT are also common causes. Womb cancer is found in a minority, around one in eleven in the largest review.
Will I be referred urgently?
In the UK, women aged 55 and over with postmenopausal bleeding should be referred on the urgent suspected cancer pathway. In England it aims for a diagnosis or all-clear within 28 days. Under 55, your GP should consider it. It's about speed, not a diagnosis.
Is bleeding on HRT normal?
A monthly bleed on sequential HRT is expected, and spotting in the first months of continuous HRT is common. Bleeding that continues beyond about six months, or starts after a bleed-free spell, should be checked.
Does a smear test check for womb cancer?
No. Cervical screening checks the cervix only. Bleeding after menopause needs its own assessment.
What does the ultrasound show?
It measures the thickness of the womb lining. A thin lining is reassuring. A thicker one usually leads to a biopsy or hysteroscopy to find out why.
Sources: Clarke MA et al., Association of endometrial cancer risk with postmenopausal bleeding in women: a systematic review and meta-analysis, JAMA Intern Med 2018;178(9):1210-22 · National Institute for Health and Care Excellence, Suspected cancer: recognition and referral (NG12) · National Institute for Health and Care Excellence, Menopause: identification and management (NG23) · Educational only, not medical advice. If you have any bleeding after menopause, contact your GP.
Keep reading: Heavy or erratic periods in perimenopause · HRT side effects · Vaginal dryness after menopause · Cervical screening in your 40s, 50s and 60s · Take the free Hormone Quiz