Introduction Recurrent postmenopausal bleeding (PMB) occurs in 6–25% of postmenopausal women. Controversy exists as to whether recurrent PMB leads to a higher risk of endometrial cancer (EC) in comparison to a first presentation of PMB. Additionally, little is known about predictive factors for recurrent PMB.

Methods We conducted an observational multicenter prospective cohort study over a 7 year period in four hospitals in the Netherlands. Women aged ≥40 years with PMB undergoing endometrial sampling were included after written consent was obtained. Occurrence of recurrent PMB was retrospectively determined. Chi-square, univariate and multivariate analysis were performed using SPSS28 to compare pathological outcomes and identify predictive factors. Central study approval was obtained (MEC 2015–740).

Results We included 468 women, of whom 28% experienced recurrent PMB. Median follow-up time was 61 months (IQR 54–69). Compared to women with recurrent PMB, women with one episode of PMB were more often diagnosed with a malignancy (RR 1.979, 95% CI 1.071–3.657, p=0.023) and less frequently with benign polyps (RR 0.735, 95% CI 0.547–0.987, p=0.045). Identified predictive factors for recurrent PMB include higher BMI (OR 1.041, 95% CI 1.004–1.079, p=0.03) and use of hormone replacement therapy (HRT) (OR 2.754, 95% CI 1.476–5.138, p=0.001). Presence of polyps was not independently associated with recurrence (OR 1.527, 95% CI 0.978–2.385, p=0.063).

Conclusion/Implications Recurrent PMB occurred in 28% of postmenopausal women. Women with recurrent PMB were less often diagnosed with malignancies and more frequently with benign polyps, compared to women with one episode of PMB. Predictive factors for recurrent PMB include high BMI and HRT.