Bleeding after the menopause

What counts as bleeding after the menopause

Bleeding after the menopause (postmenopausal bleeding, often shortened to PMB) means any bleeding from the vagina 12 months or more after your last period. It includes spotting, a pink or brown discharge, and bleeding that you notice only when you wipe or after sex. It counts even if it happened only once, was very light or has already stopped. If you are unsure whether blood is coming from the vagina, the bladder or the bowel, it should still be checked.

If you take HRT (hormone replacement therapy), some bleeding can be expected. Cyclical (sequential) HRT gives a planned bleed each month, and with any type of HRT, unexpected bleeding is common in the first six months after starting, or for about three months after a change of dose or type.

Bleeding outside these patterns, bleeding that continues beyond them, or heavy or prolonged bleeding at any time should be assessed. Your GP or HRT prescriber may adjust your HRT first or arrange a scan, depending on your HRT and your own risk factors, following the joint UK guideline on unscheduled bleeding on HRT ^[3].

Why it should always be checked

In most women the cause turns out to be minor, such as thinning of the tissues or a small polyp. When the observational studies are pooled, about 9 in 100 women with bleeding after the menopause turn out to have cancer of the lining of the womb (endometrial cancer); the other 91 do not ^[1].

About nine in ten women who have this cancer have bleeding after the menopause, whatever its stage ^[1]. That is why every episode should be checked, whatever your age and however light the bleeding. Checking promptly means that, if cancer is present, it is more likely to be found early, when it is easier to treat.

The NHS route and seeing me privately

Your GP can refer you urgently to a hospital gynaecology clinic, often a dedicated postmenopausal bleeding clinic, on the NHS suspected cancer pathway (you may hear it called a two-week wait referral). NICE advises this referral for women aged 55 and over with bleeding after the menopause that is not explained by HRT, and asks GPs to consider it for younger women too ^[2]. The name can sound alarming, but most women referred this way do not have cancer: the pathway simply makes sure that the cause is found without delay.

You are also welcome to see me privately. Please do not let arranging a private appointment delay your GP referral: see your GP as well, and take whichever appointment comes first.

If you are paying for yourself, you can book directly. If you have private medical insurance, check whether your insurer needs a GP referral and obtain a pre-authorisation number before you book. My practice manager, Helen, can help you choose a clinic (the CRP Clinic accepts Bupa and self-pay patients only), and my fees are on the fees and insurance page.

Common causes

• Thinning of the vaginal tissues or the lining of the womb (atrophy). Lower levels of oestrogen (the main female hormone) after the menopause make these tissues thinner and more fragile, so they bleed easily. This is one of the commonest causes.
• Polyps. These are small, soft growths from the lining of the womb or the cervix (the neck of the womb). Most are benign (not cancerous), and they are usually removed and checked in the laboratory.
• Thickening of the lining of the womb (endometrial hyperplasia). This happens when oestrogen stimulates the lining without enough of the hormone that balances it, which is more likely with some types of HRT and in women who are overweight. Some forms, particularly those with abnormal cells (atypical hyperplasia), can develop into cancer if untreated.
• Bleeding related to HRT, as described above.
• Less often, cancer. This is usually cancer of the lining of the womb (endometrial cancer, also called womb cancer), and rarely cancer of the cervix, vagina, vulva or ovary.

Blood-thinning medicines make bleeding more likely, and bleeding while you take them still needs checking.

How I assess bleeding after the menopause

I will ask about the bleeding, your medicines (including any HRT, or hormone treatment after breast cancer, which can affect the lining of the womb), your general health and your cervical screening. With your permission I will examine you, usually including a speculum examination (with the same instrument used for cervical screening) to look at the vagina and cervix, as some bleeding comes from there.

The key test is an internal (transvaginal) ultrasound scan, using a slim probe placed gently in the vagina, to measure the thickness of the lining of the womb (the endometrium). In women who are not taking HRT, a lining of 4 mm or less is usually reassuring: fewer than 1 in 100 women with a lining this thin turn out to have cancer ^[4], so after a single episode of bleeding further tests are often unnecessary. If the bleeding settles, no treatment is needed, and you come back if it returns.

If the lining is thicker, if the scan suggests a polyp, or if the lining cannot be seen clearly, I will usually recommend a closer look. If you take HRT, a lining of 4 mm or less on continuous combined HRT, or 7 mm or less on cyclical HRT, is usually reassuring ^[3].

The decision never rests on one measurement alone: it also depends on your symptoms, whether the bleeding has come back, any hormone treatment, your own risk factors and the rest of the scan.

Ultrasound is also less reliable when fibroids (non-cancerous growths in the wall of the womb) make the lining hard to see. A study that modelled the test in Black and White women in the United States found that the 4 mm measurement would miss almost five times as many cancers in Black women, because fibroids, and types of womb cancer that the measurement shows less well, are both more common ^[5]. In these situations I may recommend a hysteroscopy even if the lining appears thin.

At Parkside Hospital in Wimbledon and the CRP Clinic in Epsom, I scan you myself during the consultation, so we can usually discuss the findings at the same visit. At Spire St Anthony’s Hospital in Sutton and Ashtead Hospital, scans are arranged separately: I order the scan, you have it at the hospital, and I see you again to go through the results.

If you need a hysteroscopy

If a closer look is needed, I will recommend a hysteroscopy (looking inside the womb with a slim telescope passed through the cervix), usually with a small sample of the lining (an endometrial biopsy) for the laboratory. It lets me see the lining directly, take samples from the right place and often remove a polyp at the same time.

Many women feel period-like cramps that settle quickly, while some find a hysteroscopy painful, so you can choose how you are kept comfortable:

• Inhaled pain relief, breathed through a hand-held inhaler that you control yourself, for an outpatient hysteroscopy at the CRP Clinic in Epsom.
• Sedation or a general anaesthetic in hospital, so that you are relaxed and drowsy, or asleep. You usually go home the same day.

A local anaesthetic into or around the cervix can be added to either, and a nurse is present throughout. I carry out more than 150 hysteroscopic procedures a year on average, and I introduced inhaled pain relief for outpatient gynaecology at Epsom Hospital, in my NHS practice (about these figures).

If you are awake, you can ask me to stop at any time, and the Royal College of Obstetricians and Gynaecologists advises that every woman is told about the other settings and kinds of anaesthetic beforehand ^[6]. Complications are uncommon.

Before you decide, I will go through the risks, including infection, bleeding and a small tear in the wall of the womb (perforation).

Treatment depends on the cause

Once we know the cause, we go through the options together and decide together what the best option is for you. The treatment of a thickened lining follows the joint guideline of the Royal College of Obstetricians and Gynaecologists and the British Society for Gynaecological Endoscopy ^[7].

• Thinning (atrophy). Many women need no treatment once other causes have been ruled out. If dryness or bleeding continues, local hormone treatment (a low-dose hormone cream, pessary or ring placed in the vagina) usually helps, as can vaginal moisturisers.
• Polyps are removed by hysteroscopy, often in the same procedure in which they are found, and checked in the laboratory.
• Thickening of the lining (endometrial hyperplasia). Without abnormal cells, careful watching with repeat samples is sometimes enough, but it is usually treated with a hormone-releasing coil or other hormone treatment, with repeat samples at six months to check that it has settled; UK guidance says fewer than 5 in 100 women with this form go on to develop cancer over 20 years. With abnormal cells (atypical hyperplasia), the risk of cancer is higher, so I usually recommend a hysterectomy (removal of the womb) with the tubes and ovaries, by keyhole surgery (laparoscopic or robotic surgery through small incisions) where suitable, as the same guidance advises.
• Bleeding related to HRT. Adjusting the type or dose of HRT often helps, and I can advise on this.
• Cancer. If the tests show cancer, I will refer you to a gynaecological oncology team (specialists in cancers of the womb, cervix and ovaries), who will arrange any further tests and plan your treatment with you. I will make sure you know what happens next and who to contact.

If the bleeding comes back, even after reassuring tests, please tell your GP or contact my practice manager, Helen, because it should be checked again.

When to seek urgent help

Bleeding after the menopause is usually light and can be assessed at a planned appointment. Seek help straight away if you are bleeding heavily, for example soaking through pads or passing large clots, or if you feel faint, dizzy, breathless or unwell. Contact NHS 111 or go to your nearest emergency department, and call 999 in an emergency. Please do not wait for a clinic appointment in these situations.