To estimate the prevalence of genital tract diseases in women with initial and recurrent postmenopausal bleeding (PMB) to help inform diagnostic pathways.Prospective cohort study (Canadian Task Force classification: II-2).Large urban teaching hospital.Of 1938 consecutive women with postmenopausal bleeding, 106 (5%) were investigated for a recurrent episode after having normal findings of previous investigations.All women underwent pelvic examination and ultrasound scanning. An endometrial biopsy was performed when endometrial thickness was >4 mm in women with a first episode of PMB, with recourse to outpatient hysteroscopy after correlation between clinical and pathologic findings. All women with a recurrent PMB episode underwent endometrial biopsy and outpatient hysteroscopy.The risk of having endometrial cancer or hyperplasia with atypia was significantly less in women with recurrent PMB (9%) as compared with those with a first episode of PMB (8%) (p = .002), but were significantly more likely to have benign endometrial polyps (28%) compared with women with a first episode of PMB (19%) (relative risk, 1.47; 95% confidence interval, 1.07-2.02; p = .02).Recurrent PMB results in less likelihood of premalignant and malignant endometrial disease; however, in 1 of 4 women PMB is caused by endometrial polyps. First-line investigation in women with recurrent PMB should be tests that have high accuracy for enabling diagnosis of focal diseases, such as outpatient hysteroscopy or saline infusion sonography.