A 63-year-old woman presented with a 3-day history of vaginal bleeding. Pelvic examination and ultrasound revealed bilateral atrophy of the ovaries and a uterus of 8.8 x 3.3 x 4.0 cm. Serum estradiol (E2) was 300 pg/mL. Cushing syndrome was diagnosed biochemically, and computed tomography of the abdomen revealed a 5-cm left adrenal mass and tumors in the liver and lung. A pathologic diagnosis of metastatic adrenal carcinoma was made after surgery. This case demonstrates that adrenal carcinoma can produce high E2 levels in a postmenopausal woman, leading to uterine enlargement and vaginal bleeding. Adrenal carcinoma should therefore be included in the differential diagnosis of postmenopausal vaginal bleeding.