Bleeding after menopause: is it always cancer, and what happens next?

Your periods stopped a year or more ago. You thought that part of life was over. Then you notice blood on the loo paper, a brown mark in your knickers, or a bleed that looks just like a period. It's natural to feel scared, and to search late at night for whether bleeding after menopause is always cancer.

It isn't. The NHS says bleeding after the menopause is not usually serious. But it can be a sign of cancer, so it always needs to be checked by a GP. Even if it's only a small amount, and even if it's only happened once.

This page explains what usually causes it and what happens next. The short version: book an appointment now, and try not to assume the worst.

What counts as bleeding after menopause?

Bleeding after menopause (doctors call it postmenopausal bleeding) is any bleeding from the vagina after your periods have stopped. The NHS says menopause is usually diagnosed in women over 45 who haven't had a period for more than a year.

So if it's been 12 months or more since your last period, any blood counts. That includes:

• spotting after menopause, such as a pink or red smear when you wipe
• a heavy bleed, or bright red blood, like a period
• brown discharge, or a brown stain in your underwear
• bleeding after sex

The NHS menopause page is clear: if you haven't had a period for 12 months or more and you have any vaginal bleeding, see a GP.

If it's been less than a year since your last period, you're probably still in perimenopause. Our pages on perimenopause spotting and period changes explain what's usual then.

Is bleeding after menopause always cancer?

No. Most of the time it isn't. The NHS says it's not usually serious, and that cancer is a less common cause.

A leaflet from Dorset County Hospital NHS Trust gives a rough idea of the numbers. It says about 90% of women (9 in 10) have no serious cause, or a cause that isn't cancer. In a small number, about 10% (1 in 10), it can be caused by something more serious, like cancer of the womb.

That's why the NHS asks every woman to get it checked. Not because it's likely to be cancer, but because it sometimes is, and the NHS says cancer may be easier to treat if it's found early.

What causes bleeding after menopause?

The NHS lists these causes:

Cause	What it means
Thinning of the vaginal lining (atrophic vaginitis)	Caused by lower oestrogen levels. Common
Thinning of the womb lining (endometrial atrophy)	Also caused by lower oestrogen. Common
Polyps on the cervix or in the womb	Small growths. Usually not cancer. Common
Thickened womb lining (endometrial hyperplasia)	Can be caused by HRT, high oestrogen levels or being overweight. It can lead to womb cancer, so it's watched or treated
A side effect of HRT	See the HRT section below
Cancer, such as womb cancer or ovarian cancer	Less common

Vaginal dryness is common after menopause. The NHS lists spotting or bleeding among its signs. But the same page says to see a GP about bleeding after menopause. So please don't put it down to dryness without a check first.

Heavy bleeding after menopause, bright red or brown: does the colour matter?

Not for deciding whether to get it checked. The NHS advice is the same for any bleeding after menopause, however much or little, and whatever the colour.

Heavy, bright red bleeding can be frightening. If you're bleeding very heavily and you're not sure how urgent it is, call NHS 111. If it feels life-threatening, call 999.

Brown discharge after menopause can be hard to read. You may not be sure if it's blood at all. Treat it as bleeding and mention it to your GP. The NHS lists a change in vaginal discharge among the symptoms worth checking, and its vaginal discharge page says to see a GP if a change in colour is worrying you.

Bleeding after menopause and back pain

Back pain on its own is very common. The NHS says it usually isn't serious and often gets better within a few weeks.

But the NHS womb cancer page lists pain in your lower back among the other possible symptoms, alongside bleeding after menopause.

So if you have bleeding and back pain, tell your GP about both. Don't wait for the back pain to settle before you book. The NHS also says these symptoms are common, can have many causes, and don't mean you definitely have cancer.

Bleeding on HRT

HRT can cause bleeding, and some of it is expected. The NHS says:

• irregular bleeding or spotting is common in the first few months of HRT, and usually settles within 6 months
• on some types of HRT, a monthly bleed (a withdrawal bleed) at the end of each course of progestogen is normal
• on continuous combined HRT, irregular bleeding or spotting is common for the first 4 to 6 months

The NHS says to tell your GP about irregular bleeding at your first review, after about 3 months. See a GP if:

• you're still bleeding more than 6 months after starting HRT
• the bleeding gets heavier
• you start bleeding after you hadn't had periods for a while

If you're not sure whether your bleeding is expected, ask. Please don't stop or change your HRT without talking to your GP first.

What happens when you see your GP?

Your GP will ask about the bleeding. It helps to note when it started, how much there was, the colour, and whether it came after sex. The Dorset leaflet also suggests noting your age at menopause and any medicines you take.

The NHS says your GP should refer you to a hospital or a postmenopausal bleeding clinic. You should not have to wait more than 2 weeks to see a specialist.

Being referred quickly can feel alarming. But it's simply how the NHS makes sure bleeding after menopause is checked properly. The NHS says an urgent referral does not definitely mean you have cancer.

What tests will I have?

At the clinic, a specialist (who may be a nurse) will look for the cause. The NHS says tests may include:

• A vaginal ultrasound scan. A small device is placed in your vagina to scan for problems.
• A pelvic and vaginal examination. A speculum is used to look at your vagina and cervix.
• A physical examination. The specialist presses on your tummy, and inside your vagina, to check for lumps, tenderness or swelling.
• A hysteroscopy and biopsy. A thin camera is passed through your cervix to look inside your womb, and a small sample of tissue (a biopsy) is taken for testing.

You may not need every test. The Dorset leaflet says that if the scan shows the womb lining is very thin, you may only need the speculum examination. If it's thicker, you'll be offered a hysteroscopy and a biopsy. It says a biopsy usually takes a couple of minutes.

Will a hysteroscopy hurt?

It's a fair question, and the NHS is honest about it. The NHS hysteroscopy page says it often feels like period pain, and for many people it can be very painful. It usually takes 10 to 15 minutes.

Some things that can help:

• The NHS says taking ibuprofen or paracetamol an hour before can help. Check with the clinic or a pharmacist what's right for you.
• You can ask about gas and air, a local anaesthetic, or whether sedation or a general anaesthetic is possible. Not every clinic offers these.
• You can bring someone with you, and you can ask to stop at any time.
• Tell the staff beforehand if you've had painful examinations before, or anything that makes this hard for you.

What happens next?

Treatment depends on the cause. The NHS says:

• thinning of the vaginal or womb lining may need no treatment, or oestrogen cream or pessaries
• polyps may need to be removed by a specialist
• a thickened womb lining may need no treatment, hormone medicine or, sometimes, a hysterectomy
• if HRT is the cause, your doctor may suggest changes to it
• if cancer is found, treatment is usually surgery, sometimes with other treatments

If the bleeding comes back after you've been checked, see your GP again.

While you wait

Waiting for tests is hard. It can help to tell a friend or partner, who could come with you. If the bleeding changes or gets heavier, let your GP know.

When to see your GP

See your GP about:

• any bleeding or spotting a year or more after your last period, even once
• brown or pink discharge, or a change in your discharge
• bleeding on HRT that is unexpected, heavier, or still going after 6 months

You may also find these pages useful: perimenopause spotting, perimenopause period changes and our guide to post menopause symptoms.

This page is general information, not medical advice. If you're worried about any symptom, please talk to your GP or pharmacist.

See all perimenopause symptoms