Is spotting normal after menopause?

Is Spotting Normal After Menopause?

No, spotting or any vaginal bleeding after menopause is never normal and always requires urgent medical evaluation to exclude endometrial cancer and other serious pathology. 1

Why This Matters for Patient Outcomes

• Endometrial cancer is present in approximately 10% of women with postmenopausal bleeding, making this a red-flag symptom that cannot be dismissed as "normal spotting." 2, 3
• The peak incidence of endometrial carcinoma occurs between ages 65-75 years, precisely when women might attribute bleeding to benign causes. 2
• All postmenopausal bleeding should trigger urgent referral and evaluation, as early detection dramatically impacts survival in endometrial cancer. 2

What Patients Need to Know at Menopause

The American Cancer Society guidelines explicitly state that at the time of menopause, women should be informed about the risks and symptoms of endometrial cancer and strongly encouraged to report any unexpected bleeding or spotting to their physicians. 1

This counseling is a standard recommendation across all major cancer screening guidelines from 2005 through 2019. 1

Special Considerations for Women on Hormone Therapy

• Postmenopausal women taking selective estrogen receptor modulators (SERMs) like tamoxifen must report any vaginal spotting or bleeding immediately, as these medications slightly increase endometrial cancer risk. 1, 4
• Women on hormone replacement therapy (HRT) may experience breakthrough bleeding, but this still requires evaluation to exclude malignancy, as the increased likelihood of endometrial adenocarcinoma in postmenopausal women means spontaneous bleeding must always be appropriately assessed. 5
• Annual gynecologic assessment is specifically recommended for postmenopausal women on SERM therapies. 1

Required Diagnostic Workup

When postmenopausal bleeding occurs, the evaluation pathway is:

• Transvaginal ultrasound (TVUS) is the first-line imaging test to measure endometrial thickness and identify structural abnormalities. 4, 6
• Endometrial thickness ≤4 mm has a negative predictive value for cancer of nearly 100%, and if bleeding has stopped with normal examination, no further action may be needed. 4, 2
• If endometrial thickness is ≥5 mm, endometrial tissue sampling via office biopsy is mandatory. 4
• If initial biopsy is negative but bleeding persists, fractional dilation and curettage (D&C) under anesthesia should be performed. 4

Common Pitfalls to Avoid

• Never reassure a patient that postmenopausal spotting is "normal" or "just hormonal" without proper evaluation—this delays cancer diagnosis. 2, 3
• Do not rely on Pap smear to evaluate postmenopausal bleeding, as it screens for cervical cancer, not endometrial pathology. 4
• Even in the presence of benign findings like fibroids, uterine sarcoma and endometrial cancer must still be ruled out, especially as sarcoma risk increases to 10.1 per 1,000 in women aged 75-79 years. 4

Benign Causes Still Require Diagnosis

While 90% of postmenopausal bleeding has benign causes including vaginal atrophy, endometrial polyps, cervical polyps, or hormone-producing ovarian tumors, the 10% cancer risk mandates that every case be evaluated as potentially malignant until proven otherwise. 2, 3