Perimenopause Bleeding: Symptoms and Treatment

Is spotting between periods normal?

Is spotting normal during perimenopause? If you observe small amounts of blood on your underwear between cycles (which don’t require the use of a tampon or pad), it’s considered spotting. 

Aside from hormonal changes, perimenopause spotting is also the direct result of endometrial buildup. It happens either before your period starts or near the end of it. If you’re spotting between periods, however, it might be an indication of hormonal imbalance and should be discussed with your doctor. 

What changes in menstruation can you expect?

During perimenopause, your body undergoes a shift in progesterone and estrogen levels. Estrogen, specifically, rises and falls in an arbitrary manner, which in turn affects ovulation and menstrual cycles. Expect to see irregular periods, spotting, missed periods, and certain perimenopausal bleeding patterns. 

Occasionally, you’ll notice heavier and longer periods (when estrogen spikes), while at other times, you’ll notice lighter and shorter periods (when estrogen drops). Early perimenopause tends to produce shortened menstrual cycles (2 to 3 weeks long, not four) as well as periods lasting 2 to 3 days less. In contrast, late perimenopause creates longer cycles (36 days or more), often associated with anovulatory menstruation (ovulation does not occur).

Furthermore, missed periods might sometimes be followed by normal periods as perimenopausal bleeding patterns and cycles are highly irregular. In this phase, menstrual blood ranges in color from dark brown to bright red. You might notice brown discharge or perimenopause brown spotting throughout the month. The texture of your discharge will also vary from thin and watery to thick and clumpy. 

What is considered abnormal perimenopause bleeding?

Typical irregularities aside, certain cases of perimenopausal bleeding could require closer medical attention. The following are considered abnormal perimenopausal bleeding patterns:

• Very heavy menstrual bleeding, particularly with clotting (e.g., you need to change your tampon/pad hourly for several consecutive hours)
• Bleeding after sexual intercourse
• Bleeding or perimenopausal spotting between periods 
• Several short menstrual cycles (roughly 3 weeks in length)
• Several periods lasting much longer than usual
• Bleeding after one year of having no periods at all

What causes heavy bleeding during perimenopause?

Approximately 25 percent of women experience heavy perimenopausal bleeding, also referred to as menorrhagia, flooding, or hypermenorrhea. Potential reasons for increased menstrual flow include:

• An imbalance of estrogen and progesterone hormones
• Fibroids: benign tumors, which may grow larger and cause heavy perimenopausal bleeding (especially if the fibroid is located in the uterine cavity) 
• Endometrial hyperplasia: a thickening of the uterine lining that leads to irregular bleeding
• Endometrial polyps: small, noncancerous tissue growths in the uterine lining enlarged by the onset of perimenopause 
• Thyroid problems: heavy perimenopausal bleeding is sometimes brought on by an underactive thyroid, or hypothyroidism
• Polycystic ovarian syndrome: an endocrine disorder that produces irregular periods along with abnormal bleeding in the uterus 

How to treat abnormal bleeding and spotting during perimenopause

How to effectively manage heavy bleeding and perimenopause spotting is generally determined according to what’s causing it. 

Various medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), are available to decrease vaginal bleeding and provide pain relief. Tranexamic acid, for example, is known to significantly reduce menstrual flow. Additionally, oral contraceptives have the potential to regulate your cycles while also addressing bleeding problems. However, the use of contraceptives to inhibit perimenopausal bleeding is widely debated. 

When prescription drugs prove insufficient, a more advanced medical procedure may be necessary. If endometrial polyps are to blame for heavy bleeding, your doctor will likely advise surgical removal. Endometrial hyperplasia, on the other hand, is treated with progestin therapy (in the form of an intrauterine device or IUD insertion) to shed the endometrium. Thickened areas of the endometrium can also be eliminated by dilatation and curettage, which is the surgical removal of the lining or contents of the uterus. 

When to seek medical attention

Be sure to consult your doctor immediately should you experience any of the following symptoms:

• Very heavy perimenopausal bleeding (needing to change your tampon/pad hourly)
• Menstrual bleeding that lasts for more than a week
• Bleeding (but not perimenopause spotting) which occurs more often than every three weeks

The stage prior to menopause is known as perimenopause and is characterized by sharply fluctuating hormone levels (namely, progesterone and estrogen) each month. This hormonal shift has a major impact on ovulation and your menstrual cycle. 

During this phase, you might experience unpredictable perimenopausal bleeding patterns, ranging from shorter or longer periods to no periods at all. Be aware of the differences between typical and abnormal perimenopausal bleeding. If the latter appears during perimenopause, note the symptoms and make an appointment to see a medical professional.