Bleeding After Menopause: Why It Needs a Check and What Tests Come Next

Your periods stopped a year or more ago, and now there’s a pink smear on the tissue or a spot in your underwear. It’s tempting to wait and see. Bleeding after menopause is often caused by harmless conditions, but it’s also the most common early sign of uterine (endometrial) cancer, so it always deserves a call to your clinician.¹

What the numbers show

A review of 129 studies, including more than 34,000 women with bleeding after menopause, found:¹

• About 9 in 100 were diagnosed with endometrial cancer. Most were not.¹
• About 91 in 100 women with endometrial cancer had bleeding after menopause, which is why a quick check can catch it early.¹
• The risk varied with things like hormone therapy use.¹

Common harmless causes include thinning tissue, polyps and hormone therapy. Our guide to bleeding on hormone therapy covers that situation.

The usual first test: a transvaginal ultrasound

A small probe placed in the vagina measures the thickness of the uterine lining. Our article on pelvic ultrasound describes the visit. A thin lining often means cancer is unlikely, while a thicker one leads to a biopsy.²

When ultrasound isn’t enough

A 2021 simulated study using U.S. cancer registry data found that the common 4 mm cutoff would have prompted a biopsy for about 88% of cancers in white women but fewer than half in Black women.² The authors linked this to fibroids, which make the lining harder to measure, and to cancer types that don’t always thicken it.² If the lining can’t be seen clearly, or bleeding continues, ask whether you should have a biopsy anyway.

The biopsy

An endometrial biopsy takes a small tissue sample through the cervix, usually in the office. Our guides to biopsy results, saline ultrasound versus biopsy and hysteroscopy explain the next steps if more testing is needed.

Questions to ask

1. Could you see my uterine lining clearly on the ultrasound?
2. Do fibroids make my results harder to read?
3. Should I have a biopsy even if the lining looks thin?
4. What should I do if the bleeding comes back?

Try: “I had spotting this week, and my last period was two years ago. Could you see me soon, and what tests will I need?”

Period, Handled includes a Period Scorecard and a visit script. Use them to record each day of bleeding, its color and amount, and any hormone therapy you take. See the book.