Noticing bleeding after your periods have stopped can be frightening. It is also common, and it has a clear, well-tested way of being checked. This page walks you through each test, what it feels like, and what the results mean — so you know what to expect at every step.
The short answer: after bleeding after menopause, most women need only one or two simple tests. The first is an internal ultrasound to measure the womb lining. If the lining is thin (4 mm or less) and the bleeding does not come back, that is usually reassuring. If it is thicker, or the bleeding comes back, a small sample of the lining is taken — usually in the clinic, in a few minutes — or the womb is looked at with a thin camera (hysteroscopy). Most women who have these tests do not have cancer.
On this page
- Your tests at a glance
- Step 1: The first visit and examination
- Step 2: Transvaginal ultrasound
- Step 3: Endometrial biopsy
- Step 4: Hysteroscopy
- Understanding your results
- Questions to ask your gynaecologist
- Cost, language help and when to get urgent care
Your tests at a glance
- A first visit — questions about the bleeding and your medicines, and a gentle pelvic examination.
- A transvaginal ultrasound — measures how thick the womb lining is.
- An endometrial biopsy — only if the lining is thick, looks unusual, or the bleeding keeps coming back.
- A hysteroscopy — only if a biopsy is not possible or not enough, or if a polyp needs removing.
The pathway is well established and can usually reach a diagnosis within two to three weeks of the first appointment. Its priority is to rule out endometrial (womb-lining) cancer, which is found in approximately 5–10% of women with postmenopausal bleeding — more often in women with extra risk factors such as obesity, diabetes, never having given birth (nulliparity) or a late menopause.
Step 1: The first visit and examination
Your gynaecologist will ask when the bleeding started, how heavy it was, whether it has happened more than once, and which medicines you take — especially hormone replacement therapy (HRT), tamoxifen or blood thinners, because these can cause bleeding or change how test results are read.
They will then examine you, usually including a speculum examination to look at the vagina and cervix. This checks whether the bleeding is coming from the womb, the cervix or the vaginal skin. If your cervical screening is not up to date, it may be done at the same visit.
Step 2: Transvaginal ultrasound
Transvaginal ultrasound (TVUS) — a scan with a small probe placed in the vagina — is the first test. It gives a much clearer picture of the womb than a scan over the tummy. It may feel a little uncomfortable but should not be painful, and it takes around 10–15 minutes.
What does “4 mm” mean on my scan?
The scan measures the thickness of the womb lining (endometrial stripe). A womb lining of 4 mm or less is reassuring — the risk of endometrial cancer with a thin endometrium is under 1%. If the lining is above 4 mm, looks unusual on the scan, or if bleeding recurs despite an initially normal ultrasound, an endometrial tissue sample is needed.
If you take HRT or tamoxifen
HRT and tamoxifen can make the womb lining look thicker on a scan, so the 4 mm guide is less reliable. Your gynaecologist may suggest a biopsy or hysteroscopy sooner. Do not stop these medicines on your own — ask your doctor first.
Step 3: Endometrial biopsy
Do I need a biopsy after postmenopausal bleeding?
Not always. Many women need only the scan. A biopsy is advised when the lining is thicker than 4 mm, looks unusual, or the bleeding keeps coming back.
What happens during the biopsy
Outpatient endometrial biopsy (Pipelle sampling) is performed in the outpatient clinic without anaesthesia. It obtains a tissue sample from the uterine lining for checking under a microscope (histology): a thin, flexible tube is passed through the cervix to collect a small piece of the lining. The procedure takes under 5 minutes. It can cause cramping like period pain for a short time, and taking a painkiller beforehand can help. Results usually take about one to two weeks. In the majority of cases, this provides a definitive answer. Read what an endometrial biopsy involves.
Step 4: Hysteroscopy
Hysteroscopy and directed biopsy is used when the Pipelle sample is not possible or not enough (a narrow cervix, called stenosis, or too little tissue) or when a polyp or a single abnormal area (focal lesion) needs direct assessment and removal. A thin camera is passed through the cervix to look inside the womb, and samples or polyps can be taken at the same time. This is most commonly performed under light sedation or local anaesthetic in the outpatient setting.
What about a D&C? You may hear of a D&C (dilatation and curettage) — an older way of scraping the womb lining under anaesthetic. Today it is used less often, usually when the other tests are not possible, and is often done together with hysteroscopy.
Understanding your results
Doctors are looking for the cause of the bleeding. Most results fall into one of these groups:
- Thin, dry lining (atrophy) — the most common finding. Lower hormone levels after menopause make the lining fragile. It usually needs no further tests, and a vaginal moisturiser or low-dose vaginal oestrogen may be suggested.
- A polyp — a small, usually harmless growth. It is normally removed during hysteroscopy and checked under the microscope.
- Endometrial hyperplasia (a thickened lining) — the lining has grown thicker than normal. Without atypia (no abnormal cells), it is often treated with a progestogen hormone, such as a hormone-releasing coil, with follow-up biopsies. With atypia (abnormal cells), the risk of cancer is higher, and removing the womb (hysterectomy) is often recommended.
- Endometrial cancer — found in a minority of women. A diagnosis of endometrial cancer confirmed on biopsy is followed by staging investigations: pelvic MRI (to see how deep the cancer has grown into the womb muscle — myometrial invasion — and whether it has reached the cervix) and CT of the chest, abdomen, and pelvis. The vast majority of women presenting with postmenopausal bleeding who are found to have endometrial cancer are diagnosed at Stage I — where minimally invasive hysterectomy achieves a cure rate exceeding 90%. Early diagnosis truly saves lives in this cancer. Read understanding a confirmed uterine cancer diagnosis, the endometrial cancer clinical guide and stage 1 endometrial cancer treatment.
What causes bleeding after menopause? Most often a thin, dry lining, polyps or medicines such as HRT — cancer is the less common cause. See the most likely causes of postmenopausal bleeding for the full list.
Questions to ask your gynaecologist
- How thick is my womb lining, and what does that mean for me?
- Do I need a biopsy — and if so, why, and can it be done in the clinic?
- When will my results be ready, and how will I get them?
- If a polyp is found, will it be removed at the same time?
- If I have hyperplasia, what treatment and follow-up do I need?
- Should I change my HRT or tamoxifen while tests are going on?
- Who do I contact if the bleeding comes back?
It helps to take your previous scan and blood reports and a list of your medicines. See 10 things to bring to your consultation.
Cost, language help and when to get urgent care
Cost: the cost of these tests depends on the hospital and on whether they are done in the clinic or under sedation. Our care team can give you an estimate before any test — message the care team on WhatsApp.
In Hindi and Gujarati: womb-lining thickness — बच्चेदानी की परत की मोटाई / ગર્ભાશયના સ્તરની જાડાઈ; endometrial biopsy — बच्चेदानी की अंदरूनी परत की बायोप्सी / ગર્ભાશયના અંદરના સ્તરની બાયોપ્સી; hysteroscopy — कैमरे से बच्चेदानी के अंदर की जांच / કેમેરાથી ગર્ભાશયની અંદરની તપાસ.
Get urgent care if the bleeding is very heavy (soaking a pad an hour), or you feel faint, dizzy or breathless.
Dr. Nishtha Tripathi Patel provides rapid postmenopausal bleeding assessment and endometrial cancer surgery in Ahmedabad. Contact: +91 76988 00333.
This page is for general education and follows widely used guidance (ACOG, NHS). It does not replace advice from your own doctor, who can take your individual situation into account.