Bleeding after menopause

Bleeding from the vagina after your menopause. Women's Health Concern defines it as any vaginal bleeding after the menopause, and doctors call it postmenopausal bleeding, or PMB.

The NHS website explains that menopause is usually diagnosed in women over 45 who have not had a period for more than a year. So if your last period was over a year ago and you bleed now, this page is about you. It does not matter how little blood there is.

Often it feels like nothing at all. No pain, no warning. A spot on your shalwar, a streak when you wipe, a brownish stain you put down to discharge. Some women see it once, it never comes back, and they decide it was nothing.

The NHS website is clear on exactly this: once, a little, or not even sure it was blood, it still needs checking.

The NHS website lists the most common causes:

• thinning and inflammation of the vaginal lining or the womb lining, from lower estrogen levels
• polyps in the cervix or womb, growths that are usually not cancer
• a thickened womb lining, which the NHS says can be caused by HRT, high estrogen levels or being overweight, and which can lead to womb cancer

Less commonly, the NHS says, the cause is cancer, such as womb or ovarian cancer. Only the tests can say which, and getting checked is how you find out.

The European Menopause and Andropause Society (EMAS) adds two more causes: problems with how the blood clots, and medicines such as blood thinners. It still treats any bleeding after the menopause as a reason to investigate, to rule out cancer of the womb or cervix and changes in the womb lining that can lead to it. On a blood thinner or not, it needs checking.

The NHS website describes the tests a specialist may offer: an ultrasound scan with a small device placed in the vagina, an examination of the pelvis and vagina, sometimes a thin camera passed into the womb to look and take a small tissue sample, and a check of the tummy for lumps or tenderness.

The Pakistan Menopause Society's recommendations list a pelvic ultrasound and an assessment of the womb lining for postmenopausal bleeding (Table 4), and set out how doctors should investigate it step by step (section 7.3).

Treatment depends on the cause, and the NHS website matches each cause to its options. A polyp may need removing. Thinning of the vaginal or womb lining may need no treatment, or a vaginal estrogen cream or pessary. A thickened lining may need no treatment, hormone medicine or surgery, depending on its type. If HRT is behind it, the treatment may be changed or stopped. Cancer is treated by specialists.

All of it starts with the tests.

Now. Book the appointment this week, not after Eid, not after the wedding season.

On HRT, some bleeding in the first months can be expected (see the FAQs below). But the Pakistan Menopause Society lists bleeding that starts after your periods had stopped, while on HRT, among the signs that need investigating (section 7.3.1).

Taking someone with you is fine. If you would prefer a female doctor or nurse, ask when you book whether one can see you.

Bleeding after years without a period brings questions that have nothing to do with medicine. Does it count as a period? Do you stop praying? What about the fast? Women ask these quietly, and rarely get a straight answer. They belong with a qualified scholar, and Roshara does not rule on them.

What we will say: do not let the fiqh question hold up the doctor's appointment. You can ask both, in either order, in the same week.

If you want company at the appointment, a sister or a daughter is enough. You do not have to explain more than you want to.