Postmenopausal spotting refers to any bleeding from the vagina that occurs after menopause. While this isn’t uncommon, it’s never considered normal, so it’s important to talk to your doctor if you experience it. Bleeding may be light or heavy and can vary in color — from light pink to brown — and in texture, ranging from watery to clotted. If you’ve gone at least 12 months without a period and then experience vaginal bleeding, you don’t need to panic, but it’s essential to talk to a doctor.

In some cases, postmenopausal bleeding may be a symptom of endometrial cancer (also called uterine cancer). About 10 percent of postmenopausal women who experience this kind of bleeding are eventually diagnosed with endometrial cancer, according to Cleveland Clinic.

Still, there are many other possible causes of postmenopausal bleeding, which we’ll cover in this article. Your doctor can help you get an accurate diagnosis to determine the reason and recommend the best next steps to manage your health.

1. Hormone Replacement Therapy

During menopause, your body produces less of the hormone estrogen, which can lead to symptoms like hot flashes, mood changes, and night sweats. Hormone replacement therapy (HRT) helps relieve these symptoms by replacing some of the hormones your body no longer makes.

However, taking hormones can cause side effects like irregular bleeding, including bleeding after menopause. If you’ve recently started HRT, changed your dosage or type of hormones, or stopped taking it and then notice bleeding, talk to your doctor. They can help figure out whether your medication might be the reason for the bleeding.

2. Uterine Polyps

Polyps are small, usually benign (noncancerous) growths that can form in different parts of the body, including the uterus. They can sometimes cause problems, such as bleeding. In fact, the most common symptom of uterine polyps is abnormal vaginal bleeding, which may include spotting after menopause.

If your gynecologist finds uterine polyps, they may recommend treatment. This could include medication to manage symptoms or a simple procedure to remove the polyps. In many cases, doctors suggest removing them to prevent further bleeding or discomfort.

3. Vaginal Atrophy

As hormone levels drop with age, the lining of the vagina can become thinner, drier, and more fragile. This is called vaginal atrophy. The condition can cause itching, burning, or discomfort, especially during or after sex. It can also lead to spotting or light bleeding, particularly after vaginal intercourse.

Treatment options, including certain types of hormone therapy, may help relieve these symptoms and reduce the risk of bleeding.

4. Endometrial Hyperplasia

Endometrial hyperplasia happens when the endometrium (the lining of the uterus) becomes too thick. This condition isn’t cancer, but in some cases, it can increase a person's risk for endometrial cancer if it’s not treated.

The most common symptom is abnormal vaginal bleeding, which can be light or quite heavy. Endometrial hyperplasia is more likely to develop after menopause, when hormone levels shift.

If your gynecology team believes you’re at high risk for endometrial cancer, they may recommend treatment with hormone therapy or, in some cases, a hysterectomy (surgical removal of the uterus).

5. Cervicitis

Cervicitis is inflammation of the cervix, the lower part of the uterus that connects to the vagina. This inflammation can cause spotting or bleeding, especially after sex if the area is irritated.

Cervicitis is often caused by a sexually transmitted infection (STI), but it can also result from vaginal irritation or an imbalance of healthy bacteria in the vagina. Treatment typically involves addressing the underlying cause, such as antibiotics for an STI or removal of any irritants.

6. Cervical Cancer

Endometrial cancer isn’t the only type of cancer that can cause postmenopausal spotting or bleeding. Cervical cancer can also be a possible cause. In cervical cancer, cells in the cervix become abnormal and grow in ways they shouldn’t.

This often develops after exposure to the human papillomavirus (HPV), which is spread through sexual contact. If any of your partners have tested positive for HPV, your doctor may recommend extra screenings. The HPV vaccine helps prevent cervical cancer, but many adults didn’t receive it because it became widely available only after 2006.

Most cervical cancers are found early through routine Pap screenings. However, people who’ve gone through menopause may have these tests less often. That’s one more reason to talk to your doctor about any postmenopausal bleeding.

7. Bleeding From Nearby Organs

Sometimes, bleeding from other parts of the body — like the rectum or urethra — can look like it’s coming from the vagina. If you notice blood in your underwear or in the toilet, it might not be vaginal bleeding. It can be hard to tell the source on your own.

Even if the bleeding isn’t from your vagina, it’s still important to see your doctor. Bleeding from the rectum or urinary tract isn’t typical either, and your doctor can help determine where it’s coming from and what’s causing it. They’ll work with you to figure out the next steps and get the care you need.

8. Vaginal Injury

Vaginal injuries can also cause bleeding after menopause. If the vaginal tissue is torn or irritated, it may bleed until it has a chance to heal.

The most common cause of these injuries is vaginal sex, especially if there isn’t enough natural lubrication. Lower estrogen levels during menopause can lead to dryness, which increases the risk of tearing. Other factors, like stress, certain medications, alcohol, and smoking, can also reduce vaginal moisture.

Less common causes include irritation from grooming (like shaving), reactions to soaps or hygiene products that aren’t rinsed well, or friction from clothing worn without underwear. A doctor can examine the area and help determine whether an injury is causing the bleeding and recommend treatment if needed.

Talk to Your Doctor

Even if you think you know what’s causing your postmenopausal spotting, it’s important to talk to a healthcare provider. They may ask whether you’ve had any pelvic pain, unusual discharge, or other symptoms that could help narrow down the cause.

Depending on your symptoms and medical history, your doctor may recommend tests — such as a physical exam, imaging, or an endometrial biopsy — to check for endometrial cancer or another possible condition. Remember: Postmenopausal bleeding isn’t considered typical, and it’s worth finding out what’s going on. Early detection of cancer can often lead to a better prognosis (outcome).

The sooner you understand the cause, the sooner you can get the care you need.

Talk With Others Who Understand

On MyEndometrialCancerTeam, the social network for people living with endometrial cancer and their loved ones, members come together to ask questions, give advice, and share their experiences with life and care challenges related to life with endometrial cancer.

Have you experienced postmenopausal spotting? What ended up causing it and how did you find out? Share your experience in the comments below or post to your Activities feed.