Bleeding after menopause can feel scary, but it’s more common than people realize. It’s also something you should always get checked out. In this article, Nebraska Medicine OB-GYN Candace Giles, DO FACOG, explains what you need to know about post-menopausal bleeding, what causes it and when to see a doctor.

What is menopause?

Menopause means you have gone 12 full months without a period. Dr. Giles explains, “I always remind patients of this definition because many people have symptoms of perimenopause or menopause before they reach that 12-month mark.”

Hot flashes, night sweats, mood changes or irregular bleeding can happen as your hormones shift. But once you’ve hit that one-year mark with no period, you’re officially in menopause.

Can post-menopausal bleeding ever be normal?

No. Any bleeding after menopause should be checked by a doctor. If you’ve already gone 12 months without a period and start bleeding again, it’s considered post-menopausal bleeding.

“Post-menopausal bleeding should always be evaluated to rule out serious health conditions such as endometrial cancer,” says Dr. Giles. “I tell my patients that I want to rule out anything that could be a cancer or turn into one.”

Causes of post-menopausal bleeding

Several conditions can cause bleeding. Some are minor and easy to treat, while others need urgent care.

1. Vaginal dryness (vaginal atrophy)

After menopause, lower estrogen levels can make the vaginal tissue thin, dry and fragile. This can cause small tears and lead to spotting or light bleeding—especially after sex.

2. Polyps

Polyps are non-cancerous growths on the cervix or inside the uterus. They can bleed easily from walking, exercise or intercourse.

3. Hormone therapy (HRT)

If you’ve recently started hormone replacement therapy, you may have some irregular or unscheduled bleeding at first. This usually improves as your body adjusts.

4. Infections

Yeast infections, bacterial vaginosis or other vaginal infections can cause inflammation and irritation that lead to bleeding.

5. Overgrowth of the uterine lining or cancer

More serious causes include endometrial hyperplasia (thickening of the uterine lining) or endometrial cancer. These are less common but important to diagnose early.

When should I see a doctor?

If you have any bleeding after 12 months without a period, see your OB-GYN or primary care provider as soon as possible. They can evaluate the cause and guide you to the right treatment.

“If you’re in menopause and are soaking through a pad in an hour, seek emergency care right away,” says Dr. Giles. “This type of heavy bleeding is rare. It can be caused by a large mass on the cervix or in the uterus and may require urgent surgery to stop the bleeding and collect tissue samples for diagnosis.”

Diagnosing the cause of post-menopausal bleeding

A gynecologist may:

• Ask about your symptoms and when the bleeding happens.
• Do a pelvic exam.
• Perform a pelvic ultrasound to check your uterus.
• Take a small sample of the uterine lining (endometrial biopsy).

These steps help identify the cause of the bleeding so you can get the right treatment.

Treatments for post-menopausal bleeding

Treatment depends on the cause. They include:

Vaginal atrophy:

• Vaginal moisturizers or lubricants.
• Vaginal estrogen (creams, tablets or rings).
  Both hormonal and non-hormonal options can help restore comfort and reduce bleeding.

Polyps:

• Small polyps can often be removed in the clinic.
• Larger polyps may need removal in the operating room using a small camera.
  Most polyp removals are quick and low risk.

Infections:

• Antibiotics or antifungals, either by mouth or vaginally.
• Short treatment courses usually clear symptoms fast.

Uterine lining overgrowth or cancer:

• Minor procedures to remove excess tissue.
• Progesterone therapy (oral or an IUD).
• Surgery or referral to a gynecologic oncologist for confirmed cancers.

Hormone replacement therapy (HRT):

If you recently started HRT (also known as menopause hormone therapy or MHT) and notice bleeding, follow up with your prescriber. Dose adjustments may be needed. Irregular bleeding is common early on, but should still be monitored.

Why it’s important to seek care

Even though most causes of post-menopausal bleeding are not serious, getting checked helps you stay safe. Early evaluation can catch problems before they become more severe. It also helps you get relief from symptoms like dryness, irritation or discomfort that may be affecting your quality of life.