Abnormal Bleeding During Menopause - What Causes Spotting?

The menopause transition comes with numerous physical and emotional changes. One symptom in particular that can be surprising for some women is abnormal bleeding or spotting. 

It’s not uncommon for women to experience variations in menstrual regularity or flow during the menopause transition. Longer, heavier periods are commonly observed in women during midlife.⁽¹⁾ One study found that, out of 1,320 women, over 77% reported three or more episodes of bleeding that lasted 10 days or more.⁽²⁾⁽³⁾ Additionally, research shows that shorter bleeding episodes typically occur in early perimenopause, while longer episodes are more associated with later stages of the menopause transition.⁽¹⁾

Spotting during this phase of life can be influenced by a number of factors, including health conditions, body size, smoking, and more.⁽¹⁾ Understanding the common causes of menopausal bleeding and recognizing when abnormal spotting may signal a health condition enables women to better navigate the changes their bodies go through during this time and feel confident in making informed healthcare decisions.

What are the common causes of abnormal bleeding during menopause? 

Abnormal bleeding during menopause may be caused by medication use, noncancerous growths, or a gynecological health condition. Here are five common causes of abnormal bleeding during menopause: 

1. Endometrial Polyps

Polyps are growths that can develop in different parts of the body, including the endometrium. While the exact cause of polyps remains unclear, they are linked to hormone levels, particularly an increase in estrogen.⁽⁶⁾ Diagnosis typically involves a pelvic ultrasound or a hysteroscopy to visualize the interior of the uterus.

The majority of endometrial polyps are benign or noncancerous. Abnormal uterine bleeding is the most common symptom, though some women may not experience any symptoms at all. Approximately 1% of all endometrial polyps are cancerous, primarily affecting postmenopausal women.⁽⁵⁾ A doctor may recommend removing endometrial polyps in postmenopausal women who exhibit symptoms.

2. Uterine Fibroids 

Uterine fibroids are tumors that grow in the walls of the uterus. They can vary in size, ranging from tiny to as large as a grapefruit. Fibroids are commonly seen in women in their 40s to early 50s and tend to shrink in size after menopause.⁽⁷⁾

Abnormal uterine bleeding is the most common symptom associated with uterine fibroids that develop during perimenopause or menopause. These growths can also affect postmenopausal women. The exact cause of fibroids isn't fully understood, but a combination of genetic, hormonal, and environmental factors is believed to influence their growth. While most fibroids are benign, they can be cancerous in rare cases.⁽⁷⁾⁽⁸⁾

3. Endometrial Hyperplasia

Endometrial hyperplasia refers to an excessive thickening of the uterine lining. It's primarily caused by an imbalance between estrogen and progesterone, where estrogen stimulates the growth of the endometrium, but there isn’t enough progesterone to stabilize it.^(9)(10)

This condition can cause abnormal uterine bleeding, including postmenopausal bleeding. It is important to address symptoms promptly, as untreated endometrial hyperplasia can progress to endometrial cancer. A tissue sample from the endometrium is typically used for analysis and diagnosis.⁽¹⁰⁾

4. Gynecological Cancers

Cancer is a more serious cause of postmenopausal bleeding. Uterine, cervical, and ovarian cancers can all cause abnormal bleeding, particularly after menopause.⁽¹¹⁾ Endometrial cancer is the most common gynecological cancer associated with postmenopausal bleeding. It can cause symptoms such as abnormal uterine bleeding, pelvic pain, and an increase in the size of the uterus.⁽¹²⁾ 

Healthcare providers employ a variety of tools, including Pap tests, pelvic exams, transvaginal ultrasounds, and biopsies, to diagnose different gynecological cancers.⁽¹³⁾

5. Medication Use

Certain medications and supplements may cause abnormal postmenopausal bleeding as a side effect. Some blood thinners, specific breast cancer treatment drugs, and certain types of antidepressants may increase the risk of abnormal uterine bleeding.^(5)(14)(15) Individuals should speak with a healthcare provider before taking any new medications or supplements.

Which diagnostic tools are used in gynecology?

Gynecologists use a number of diagnostic tools to assess, diagnose, and maintain female reproductive health. To evaluate abnormal bleeding during the menopause transition, doctors commonly use the following diagnostic tools:

Physical Exams

Scheduled visits with a physician not only help build a medical history but also facilitate the early detection of potential abnormalities. Physical exams and pelvic exams can help healthcare providers determine the causes of spotting or heavier flows.

The United States Preventive Services Task Force (USPSTF) recommends that women ages 21 to 29 receive cervical cancer screenings every three years using cervical cytology (Pap test). For women ages 30 to 65, screenings are recommended every three years with cervical cytology, every five years with high-risk human papillomavirus (hrHPV) testing, or every five years with hrHPV testing combined with cervical cytology.⁽¹⁶⁾ 

Transvaginal Ultrasound

A transvaginal ultrasound is a diagnostic imaging tool that allows physicians to see the uterus, ovaries, and other reproductive organs to detect potential abnormalities. This procedure involves inserting a thin tube into the vagina, where the probe emits sound waves. A sonogram image is formed as the instrument records the echoes of the sound waves bouncing off the internal organs. A transvaginal ultrasound enables healthcare providers to identify fibroids, polyps, or changes in endometrial thickness.^(17)(18) 

Endometrial Biopsy

An endometrial biopsy involves extracting a small tissue sample from the lining of the uterus, or endometrium, using a flexible instrument equipped with a suction device. This outpatient procedure is often used to investigate abnormal bleeding or spotting and is crucial for detecting conditions like endometrial hyperplasia or the onset of uterine cancer.⁽¹⁹⁾

Hysteroscopy

A hysteroscopy procedure involves the insertion of a hysteroscope — a thin, telescope-like device — into the vagina to view the inside of the uterus. There are two types of hysteroscopy procedures: diagnostic and operative. A diagnostic hysteroscopy is used to assess abnormal uterine bleeding, while an operative hysteroscopy facilitates the removal of polyps or other growths that may be contributing to the abnormal bleeding.⁽²⁰⁾ 

How to Treat Abnormal Bleeding During Menopause

Once a diagnosis is established, various treatments can be implemented depending on the cause of abnormal bleeding. Physicians will consider additional factors when deciding upon treatment methods, including any existing health conditions. Bleeding related to vaginal atrophy may not require treatment, but spotting associated with fibroids, polyps, endometrial hyperplasia, or gynecological cancers may require pharmacological treatment or surgical interventions.

Hormone Replacement Therapy (HRT)

HRT introduces hormones into the body to supplement natural hormones and restore hormonal balance. While traditional HRT uses synthetically derived hormones, bioidentical HRT uses hormones that are chemically identical in structure to those produced naturally by the body. By regulating levels of estrogen and progesterone, bioidentical HRT may help relieve various menopausal symptoms, including abnormal bleeding related to hormone fluctuations.

While HRT may help manage abnormal uterine bleeding, breakthrough bleeding during treatment is common among postmenopausal women. This type of bleeding usually resolves on its own within two to three months of starting treatment. Breakthrough bleeding has also been linked to the discontinuation of HRT, a phenomenon known as withdrawal bleeding or scheduled bleeding.^{(5)(21)(22)(23)}

Dilation and Curettage

Often abbreviated as D&C, dilation and curettage involves opening the cervix and using an instrument to extract tissue from the uterine lining. In some cases, D&C may be used to treat abnormal bleeding, though it’s more traditionally employed as a diagnostic tool. However, endometrial biopsies, transvaginal ultrasounds, and hysteroscopies are more commonly used today.^(24)(25) 

Hysterectomy

In specific cases, a hysterectomy may be recommended. This procedure involves the partial or complete removal of the uterus. It’s used to treat endometrial cancer, uterine fibroids, chronic vaginal bleeding that does not respond to alternative treatment methods, and more. As a major surgery, recovery can take several weeks. If a hysterectomy is combined with an oophorectomy — the removal of the ovaries — the surgery will induce the immediate onset of menopause and may lead to a decreased libido.⁽²⁶⁾

Abnormal Bleeding During Different Stages of Menopause

Abnormal uterine bleeding accounts for about one-third of outpatient gynecological visits, particularly among perimenopausal women.⁽²⁷⁾ While bleeding is commonly reported at the onset of menopause, rates significantly decrease in the years following menopause.⁽⁵⁾ Although natural physiological changes that occur during the menopause transition may contribute to bleeding or spotting, any bleeding after menopause is considered abnormal.⁽²⁸⁾ 

Some causes, like vaginal atrophy, may not be linked to a health condition and may not require treatment. However, individuals experiencing abnormal bleeding related to polyps, fibroids, endometrial hyperplasia, or cancer may need medication or surgery.

While the initial sight of blood can be jarring, understanding the changes the body goes through during the menopause transition can help women manage bleeding with knowledge and confidence, especially under the guidance of a healthcare provider.