You have not had a period for two years. And then you suddenly see blood. Once, a small amount, perhaps light pink or bright red. Your first thought is probably the worst one.
Let me put a number next to that straight away. In an analysis of 129 studies, around 9 percent of women with bleeding after menopause had endometrial cancer (Clarke, 2018). That means that in roughly 9 out of 10 women something else is going on, and it is usually something benign.
And yet, and this is the whole point of this article: you always get it checked. Not because it is likely to be serious, but because the one time it is, it almost always starts exactly like this.
What exactly is postmenopausal bleeding?
Postmenopausal bleeding means losing blood vaginally when you have not had a period for twelve months or longer. The amount does not matter. One drop counts just as much as a real bleed, and light brown discharge belongs on the list too.
That is the most important rule in this whole piece.
Many women wait precisely because it was "only a little". I understand that, because nothing else happens and it stops on its own. But the amount says nothing about the cause.
Are you still in the middle of menopause and has your cycle only become irregular? Then that is something else. Read about it in post-menopause: what happens after menopause.
What causes bleeding after menopause?
Most causes are benign. Most often it is a thin, fragile lining of the vagina and uterus caused by the low oestrogen levels after menopause, or a polyp. Hormone therapy can also cause bleeding. Endometrial cancer is a less common but important cause, and that is exactly the one you want to rule out.
The table below gives you an honest overview.
| Possible cause | What you may notice | How often |
|---|---|---|
| Thin, fragile lining (atrophy) | Dryness, irritation, bleeding after sex | Most common cause |
| Polyp in the uterus or cervix | Irregular, often light bleeding | Common, and nearly always benign |
| Hormone therapy | Bleeding linked to your regimen | Regularly, discuss it with your doctor |
| Thickened womb lining (hyperplasia) | Usually no other complaints | Can be a precursor and is treated |
| Endometrial cancer | Often only the bleeding itself | Around 9 percent of cases (Clarke, 2018) |
Look at that bottom row once more. In around 91 percent of women who develop endometrial cancer, bleeding is the first signal (Clarke, 2018). That is exactly why this symptom carries so much weight: it is the only early sign there usually is.
A polyp is the most common "harmless" explanation, by the way. Read about it in uterine polyp: bleeding, causes and investigation.
How does the investigation work?
With bleeding after menopause, your GP usually refers you to a gynaecologist. They perform an internal ultrasound and measure the thickness of your womb lining. If the lining is thin, the chance of something serious is small. If it is thicker, tissue examination follows, for example with a thin suction tube or through a hysteroscopy.
The investigation itself is usually an outpatient procedure and does not take long.
Imagine the ultrasound shows a lining of 3 mm. That is thin, and the chance of something serious is then small. If the gynaecologist measures 9 mm, tissue examination follows to get certainty. That single measurement, one number in millimetres, decides the next step. No blood value does that here.
This is what the route typically looks like:
- GP: you report the bleeding, even if it happened only once
- Internal ultrasound: the gynaecologist measures the thickness of the lining
- Tissue examination: with a thickened lining, to get certainty
- Result: in most cases benign, with targeted treatment of the cause
The NHG guideline on vaginal bleeding describes this route for GPs, and Thuisarts.nl explains it in plain language. Feel free to take that explanation to your appointment.
What can blood tests do here, and what can they not?
Blood tests cannot detect or rule out the cause of bleeding after menopause. There is no blood test that detects endometrial cancer, and the tumour marker CA-125 is not suitable for this. The diagnosis runs through ultrasound and tissue examination, and that is the only route that gives certainty.
I want to be very clear here, because this is exactly the situation in which a self-ordered blood test can do harm.
A normal result reassures you, while the investigation you needed has not been done. That costs time, and time is the only thing that really matters with this symptom. So do not order a blood test instead of an appointment.
Where blood tests can be useful is alongside your gynaecologist's investigation:
- Hb and ferritin: if you have lost a lot of blood or bled for a long time and feel tired
- Thyroid (TSH): if you also have complaints that fit
The Anemia panel gives insight into that. But the first step with bleeding after menopause is and remains your GP, not a tube of blood.
Want to understand why that tumour marker keeps coming up here and why it is not suitable? Then read CA-125: what this tumour marker does and does not say.
When do you call your GP?
Call for any bleeding that happens after you have gone twelve months or longer without a period. Regardless of the amount, the colour and whether it happened only once. Light brown discharge or a little blood after sex counts too.
That is the whole rule. There is no small print underneath.
In any case, call for:
- Bleeding, however little, after twelve months without a period
- Bleeding after sex in the postmenopause
- Brown or pink discharge you cannot explain
- Bleeding while using hormone therapy that does not fit your regimen
If you use hormone therapy, mention it right at your appointment. It changes the assessment, but it does not make the appointment less necessary.
One more thing, and then I will let you go. Waiting costs you nothing but time, and time is exactly what you do not want to spend here. Call tomorrow.
Frequently asked questions
Is bleeding after menopause always cancer?
No. In an analysis of 129 studies, around 9 percent of women with bleeding after menopause had endometrial cancer (Clarke, 2018). In most women the cause is benign, such as a thin lining or a polyp. Even so, any bleeding after menopause should be investigated.
How much blood does it take before I call?
The amount does not matter. One drop, a trace on your toilet paper or brown discharge counts just as much as a real bleed. Call your GP even if it happened once and stopped on its own.
Can a blood test rule out something serious?
No. There is no blood test that detects or rules out endometrial cancer. The assessment runs through an internal ultrasound and, if needed, tissue examination. A normal blood result can wrongly reassure you and delay the investigation you do need.
References
- Clarke MA, et al. Association of endometrial cancer risk with postmenopausal bleeding in women: a systematic review and meta-analysis. JAMA Internal Medicine, 2018. PMID 30083701.
- Uglietti A, et al. The risk of malignancy in uterine polyps: a systematic review and meta-analysis. European Journal of Obstetrics and Gynecology and Reproductive Biology, 2019. PMID 31009859.
- Menon U, et al. Ovarian cancer population screening and mortality after long-term follow-up in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). The Lancet, 2021. PMID 33991479.
- NHG. NHG guideline on vaginal bleeding. Dutch College of General Practitioners. Available via richtlijnen.nhg.org.
- Thuisarts.nl. I have bleeding after menopause. Dutch College of General Practitioners. Available via thuisarts.nl.
Every blood test result through Lunara includes a professional assessment by a BIG-registered doctor. Bleeding after menopause is not assessed with a blood test: always discuss this with your GP.
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