You have not had a period for more than a year and you notice a few traces of blood, pinkish or brownish discharge, or real bleeding?
In the majority of cases, the cause is benign.
But bleeding after the menopause always deserves a medical assessment, because it can also be the first sign of a condition of the endometrium.
The practical rule is therefore simple: even a single or very light episode should be reported to a health professional.
What is meant by bleeding after the menopause?
The menopause classically corresponds to the permanent end of periods after 12 consecutive months without menstruation, in the absence of another obvious cause.
Postmenopausal bleeding refers to vaginal bleeding occurring after this period.
It can take different forms:
- a few traces of blood;
- pinkish or brownish discharge;
- bleeding resembling a period;
- bleeding after sexual intercourse.
The NICE guidelines also define postmenopausal bleeding as vaginal bleeding occurring more than 12 months after menstruation has stopped because of the menopause.
What are the possible causes?
Benign causes are common
Possible causes include in particular:
- vaginal or endometrial atrophy, linked to the fall in oestrogen;
- polyps of the cervix or endometrium;
- some menopausal hormone treatments;
- benign lesions of the cervix or vagina.
As oestrogen levels fall, the mucous membranes can become thinner and more fragile and bleed more easily.
Some causes must be ruled out
The assessment must also look in particular for:
- endometrial hyperplasia;
- a precancerous lesion;
- endometrial cancer;
- more rarely, a condition of the cervix, vagina or vulva.
The blood may sometimes come not from the genital tract but from the bladder or rectum. The medical examination makes it possible to identify its origin.
Does it necessarily mean cancer?
No.
The majority of women with bleeding after the menopause do not have endometrial cancer.
A major systematic review and meta-analysis published in 2018 in JAMA Internal Medicine pooled 129 studies and 40,790 women.
It showed that:
- about 9% of women with postmenopausal bleeding had endometrial cancer;
- about 91% of women with endometrial cancer had experienced postmenopausal bleeding.
These figures explain why the symptom must be assessed without immediately concluding that it is cancer.
In other words:
most postmenopausal bleeding is benign, but bleeding is a common presenting sign of endometrial cancer.
What factors increase the risk of endometrial cancer?
Individual risk depends on many factors.
Factors associated with an increased risk include in particular:
- overweight and obesity;
- diabetes;
- prolonged exposure to oestrogen without a progestogen in a person who still has her uterus;
- tamoxifen;
- certain genetic predispositions, in particular Lynch syndrome;
- certain personal or family history.
The absence of risk factors does not, however, rule out a condition of the endometrium when bleeding is present.
How is the assessment carried out?
The assessment depends on age, treatments, risk factors, whether the bleeding is a single episode or recurrent, and the results of the first tests.
The gynaecological examination
The examination makes it possible in particular:
- to look for the exact origin of the bleeding;
- to examine the vulva, vagina and cervix;
- to identify any atrophy;
- to look for a polyp or another visible lesion.
Transvaginal ultrasound
Transvaginal ultrasound makes it possible to examine the uterus, endometrium and ovaries.
It can measure the thickness of the endometrium and look for:
- thickening;
- a polyp;
- a mass;
- or another abnormality.
For many years, the recommendations of the American College of Obstetricians and Gynecologists (ACOG) considered that an endometrium measuring 4 mm or less on transvaginal ultrasound could be a sufficient initial assessment in certain situations, particularly for a first episode of bleeding.
What changed in the American recommendations in 2026
In April 2026, ACOG updated its recommendations.
The organisation now recommends, in most patients with postmenopausal bleeding, using a combination of the following in the initial assessment:
- transvaginal ultrasound;
- and an endometrial tissue sample.
This update replaces a previous approach in which transvaginal ultrasound alone could be considered sufficient in some patients with an endometrium of 4 mm or less.
ACOG's stated aim is to improve early detection and reduce the risk of missing a cancer.
Note: this is an American recommendation
This recommendation should not be presented as a universal rule or as a French recommendation.
Practice may vary according to:
- national recommendations;
- the patient's history;
- the appearance of the endometrium;
- risk factors;
- repeated bleeding;
- any hormone treatment being taken.
The doctor therefore chooses the appropriate tests according to the individual situation.
Endometrial biopsy
Endometrial biopsy consists of taking a small fragment of the lining of the inside of the uterus.
It is often performed during a consultation using a thin cannula.
The sample is then analysed by a pathology laboratory to look in particular for:
- hyperplasia;
- atypical lesions;
- or cancer.
Hysteroscopy
Hysteroscopy makes it possible to examine the uterine cavity directly using a thin camera inserted through the natural route.
It can make it possible:
- to identify a polyp;
- to locate a localised abnormality;
- to take targeted biopsies;
- and, in some situations, to treat a polyp during the same procedure.
Dr. Maazouzi performs hysteroscopy at the Hôpital Privé Beauregard, according to the medical indication.
What if I take menopausal hormone therapy?
Some hormone treatment regimens can cause bleeding, particularly:
- at the start of treatment;
- after a change of dose;
- or when the treatment regimen is changed.
Not all bleeding on hormone treatment is therefore the same situation as unexplained bleeding in a person not on treatment.
However, bleeding that is:
- unexpected;
- persistent;
- recurrent;
- or different from the usual pattern
should be discussed with your doctor.
The NICE guidelines updated in 2026 explicitly distinguish unexplained postmenopausal bleeding from bleeding that can be attributed to menopausal hormone therapy.
What if the first assessment is reassuring but the bleeding returns?
Recurrent bleeding should lead you to consult again.
A reassuring initial result does not mean that new bleeding several weeks or months later should be ignored.
A new assessment may be necessary, in particular if:
- the bleeding persists;
- it becomes heavier;
- it recurs;
- or new symptoms appear.
When should you consult quickly?
Consult without delay if:
- bleeding occurs after the menopause, even if slight;
- the bleeding returns after a first assessment;
- you take tamoxifen and have vaginal bleeding;
- hormone treatment is accompanied by unexpected, persistent or unusual bleeding.
The NICE guidelines consider unexplained postmenopausal bleeding as a symptom warranting assessment to rule out endometrial cancer, with a level of urgency adapted in particular to age.
When to call emergency services?
In the event of:
- very heavy bleeding;
- feeling faint;
- loss of consciousness;
- severe pain;
- marked weakness;
call 15 or 112 (in France).
Key points to remember
- Bleeding occurring more than 12 months after the last period must be assessed.
- Most causes are benign.
- A meta-analysis of 129 studies estimates that about 9% of women with postmenopausal bleeding have endometrial cancer.
- About 91% of women with endometrial cancer have experienced postmenopausal bleeding.
- The assessment may include a gynaecological examination, a transvaginal ultrasound and, depending on the context, an endometrial biopsy or a hysteroscopy.
- Since April 2026, ACOG has recommended combining ultrasound + endometrial sampling from the initial assessment in most patients, but this is an American recommendation.
- New bleeding after a first reassuring assessment should lead you to consult again.
Medical information: this article provides general information and does not replace a consultation. Only a medical examination can identify the cause of bleeding after the menopause and determine which tests are needed.
Medical and Scientific Sources
Clarke MA, Long BJ, Del Mar Morillo A, Arbyn M, Bakkum-Gamez JN, Wentzensen N. Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women: A Systematic Review and Meta-analysis. JAMA Internal Medicine. 2018;178(9):1210-1222. DOI: 10.1001/jamainternmed.2018.2820. PMID: 30083701. https://pubmed.ncbi.nlm.nih.gov/30083701/
American College of Obstetricians and Gynecologists (ACOG). Updated Guidance Regarding the Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Individuals With Postmenopausal Bleeding. 16 April 2026. PMID: 41990335. https://pubmed.ncbi.nlm.nih.gov/41990335/
American College of Obstetricians and Gynecologists (ACOG). ACOG Publishes Updated Guidance on Evaluation of Postmenopausal Bleeding. 16 April 2026. https://www.acog.org/news/news-releases/2026/04/acog-publishes-updated-guidance-evaluation-postmenopausal-bleeding
National Institute for Health and Care Excellence (NICE). Suspected cancer: recognition and referral — NG12. Updated 15 April 2026. https://www.nice.org.uk/guidance/ng12
Consult Dr. Yasmine Maazouzi at the Hôpital Privé Beauregard (23 Rue des Linots, Bât. B5 ICOGM, Marseille 13004) for the assessment of bleeding after the menopause.