Why Did I Bleed During Intercourse? Understanding Postmenopausal Bleeding

It can be alarming and confusing to experience vaginal bleeding after menopause. Many women believe that once their periods have stopped, they are done with any kind of vaginal bleeding. However, this isn’t always the case, and it’s a common concern that brings women to their gynecologist’s office. If you’ve noticed bleeding, especially after sexual intercourse, it’s natural to feel worried and seek answers.

Experiencing bleeding during or after intercourse, particularly after menopause, is something that should always be evaluated by a healthcare professional. While it can sometimes be due to less serious causes, it’s essential to rule out any underlying conditions that may require medical attention.

Common Causes of Bleeding During Intercourse After Menopause

Postmenopausal bleeding, including bleeding related to intercourse, can stem from various factors. Understanding these potential causes is the first step in addressing the issue.

Vaginal Dryness and Thinning (Atrophic Vaginitis)

One of the most frequent reasons for bleeding after intercourse in postmenopausal women is vaginal atrophy, also known as atrophic vaginitis. Menopause leads to a significant decrease in estrogen levels. Estrogen plays a crucial role in maintaining the thickness, elasticity, and lubrication of the vaginal tissues. As estrogen declines, the vaginal walls can become thinner, drier, and more fragile.

This thinning and dryness can make the vaginal tissues more susceptible to irritation and tearing during sexual activity. The friction from intercourse can then cause small tears in the vaginal lining, resulting in bleeding. This type of bleeding is often light, and you might notice it as spotting or light pink discharge after sex.

Alt text: Abstract image representing the complexities and varied causes of postmenopausal bleeding, relevant to women’s health concerns.

Vaginal or Cervical Polyps

Polyps are benign (noncancerous) growths that can develop in the cervix or the uterus. Cervical polyps grow on the cervix, the lower part of the uterus that extends into the vagina, while uterine polyps are found in the lining of the uterus (endometrial polyps).

These polyps are often fragile and have a rich blood supply. Intercourse can irritate or disrupt these polyps, leading to bleeding. Polyps can sometimes be asymptomatic, but when they do cause symptoms, bleeding, especially after intercourse, is a common sign.

Endometrial Hyperplasia (Thickening of the Uterine Lining)

Endometrial hyperplasia refers to a condition where the lining of the uterus (endometrium) becomes abnormally thick. This thickening is often caused by an excess of estrogen without enough progesterone to balance it out. While less common after menopause because estrogen levels are generally low, it can still occur, particularly in women taking estrogen-only hormone therapy or those who are obese.

An overgrowth of the endometrial lining can lead to irregular bleeding, which may include bleeding after intercourse. In some cases, endometrial hyperplasia can be a precursor to endometrial cancer, making it important to investigate any postmenopausal bleeding.

Endometrial Cancer

Endometrial cancer, cancer of the uterine lining, is a less common but serious cause of postmenopausal bleeding. It’s crucial to consider and rule out endometrial cancer when evaluating any bleeding after menopause because early detection significantly improves treatment outcomes.

Bleeding is often the earliest and most common symptom of endometrial cancer. While not all postmenopausal bleeding is due to cancer, it is a significant warning sign that requires prompt medical evaluation. Bleeding related to endometrial cancer may not always be directly linked to intercourse, but any unexplained vaginal bleeding after menopause warrants investigation.

Other Less Common Causes

While the above are more frequent causes, other less common factors can contribute to bleeding during intercourse after menopause:

Cervical or Vaginal Infections: Infections can cause inflammation and irritation of the vaginal or cervical tissues, making them more prone to bleeding, especially after friction during intercourse.
Medications: Certain medications, such as blood thinners (anticoagulants) and some hormone therapies, can increase the risk of bleeding or make existing bleeding more noticeable.
Cervical Ectropion: In younger women, this condition where cells from inside the cervical canal are present on the outer surface of the cervix can cause bleeding, but it’s less common after menopause. However, if it persists into menopause, it could still be a factor.
Trauma or Injury: Though less likely to be the sole cause of recurrent bleeding, direct injury to the vagina or cervix during vigorous intercourse could result in bleeding.

What to Do if You Experience Bleeding During Intercourse

If you experience any vaginal bleeding after menopause, especially bleeding associated with intercourse, it is crucial to consult with your gynecologist or healthcare provider as soon as possible. Postmenopausal bleeding is never considered normal and requires medical evaluation to determine the underlying cause and ensure any serious conditions are ruled out or treated promptly.

The Diagnostic Process:

Your doctor will typically follow a systematic approach to diagnose the cause of your bleeding:

Medical History and Discussion: Your doctor will start by discussing your medical history, including when you went through menopause, any medications you are taking, and other health conditions you have. They will ask detailed questions about the bleeding itself, such as when it occurs, how heavy it is, and if it’s related to intercourse.
Pelvic Exam: A pelvic exam is usually a necessary step. This allows your doctor to visually examine your vulva, vagina, and cervix. They can assess for any visible lesions, polyps, or signs of atrophy. They will also manually examine your uterus and ovaries.
Pelvic Ultrasound: An ultrasound is a common imaging technique used to get a clearer picture of your uterus and endometrial lining. It can help assess the thickness of the uterine lining, detect polyps, fibroids, or other abnormalities.
Endometrial Biopsy: Depending on the findings, especially if the uterine lining is thickened, your doctor may recommend an endometrial biopsy. This procedure involves taking a small tissue sample from the uterine lining to be examined under a microscope. This is crucial for ruling out endometrial hyperplasia or cancer.
Hysteroscopy and D&C (Dilation and Curettage): In some cases, if the biopsy is inconclusive or if a more thorough examination of the uterine cavity is needed, a hysteroscopy with D&C may be recommended. Hysteroscopy involves inserting a thin, lighted camera into the uterus to visualize the uterine lining directly. D&C is a procedure where tissue is gently scraped from the uterine lining for further examination.

Treatment Options

The treatment for bleeding during intercourse after menopause will depend entirely on the underlying cause identified during the diagnostic process.

For Vaginal Atrophy: Treatment often involves replenishing vaginal moisture and elasticity.
- Vaginal Lubricants and Moisturizers: Over-the-counter lubricants used during intercourse and regular use of vaginal moisturizers can alleviate dryness and reduce friction.
- Topical Estrogen Therapy: Estrogen creams, vaginal tablets, or rings can be prescribed to deliver estrogen directly to the vaginal tissues, helping to restore their thickness and lubrication.
- Systemic Hormone Therapy: In some cases, if there are other menopausal symptoms, systemic hormone therapy (pills or patches) might be considered, but this requires careful discussion with your doctor due to potential risks and benefits.
For Polyps: Polyps are typically removed surgically. This can often be done during a hysteroscopy. Polyp removal is usually straightforward and resolves the bleeding.
For Endometrial Hyperplasia: Treatment depends on the type of hyperplasia and whether there are precancerous cells.
- Progestin Therapy: Progestin medications can help balance the effects of estrogen and treat hyperplasia without atypia (abnormal cells).
- Hysterectomy: If there is atypical hyperplasia or if progestin therapy is not effective, a hysterectomy (surgical removal of the uterus) may be recommended, especially if childbearing is complete.
For Endometrial Cancer: Treatment for endometrial cancer is complex and usually involves a gynecologic oncologist. Treatment options may include surgery (hysterectomy, often with removal of ovaries and fallopian tubes), radiation therapy, chemotherapy, and hormone therapy, depending on the stage and characteristics of the cancer.

Rosa’s Story: A Common Scenario

Like Rosa from the original article, many women experience postmenopausal bleeding and understandably become concerned. Rosa’s story highlights a common scenario where postmenopausal bleeding is investigated thoroughly. In her case, a thickened uterine lining was found, leading to a D&C and hysteroscopy. Thankfully, like many women, Rosa’s results were benign. However, it’s important to note that even after a benign diagnosis, recurrence can happen, as it did for Rosa. Her case underscores the importance of ongoing monitoring and prompt evaluation of any new episodes of postmenopausal bleeding.

Act Now for Your Health

Bleeding during intercourse or any unexplained vaginal bleeding after menopause is a signal that should not be ignored. While it may be due to a benign condition like vaginal dryness, it’s essential to seek medical advice to rule out more serious causes, such as endometrial cancer. Early detection and timely treatment are key to managing any underlying condition effectively and ensuring your long-term health and well-being. Don’t hesitate to reach out to your healthcare provider – your peace of mind and health are worth it.

Last updated: October 2020

Last reviewed: February 2024

Topics: Healthy Aging, Menstrual Health, Menopause

This information is designed as an educational aid for the public. It offers current information and opinions related to women’s health. It is not intended as a statement of the standard of care. It does not explain all of the proper treatments or methods of care. It is not a substitute for the advice of a physician. Read ACOG’s complete disclaimer.

About the Author:

Dr. Tamika C. Auguste

Dr. Auguste is an obstetrician–gynecologist at MedStar Washington Hospital Center in Washington, DC, where she serves as the Interim Chairwoman of Women’s and Infants’ Services, among other leadership roles. She is a professor at Georgetown University School of Medicine and a member of the American College of Obstetricians and Gynecologists’ Board of Directors.