Is Irregular Bleeding Normal During Perimenopause?

Perimenopause is the natural decline in reproductive hormones a woman experiences when she reaches her 40s or 50s. And irregular bleeding can be a common byproduct of this shift in hormone levels. It's important to understand, however, that not all menstrual problems are caused by perimenopause or menopause.

Normal vs Abnormal Bleeding

You will likely experience changes in your menstrual cycle during perimenopause. Your periods may be either shorter or longer. You might experience heavy or lighter bleeding during your period. You may even skip periods altogether.

Several things can cause abnormal bleeding. Call your healthcare provider if you experience:

• Very heavy bleeding, to the point that you need to change your pad or tampon several times overnight
• Large blood clots during menstruation
• Periods lasting longer than one week
• Spotting between periods
• Bleeding after sex
• Dizziness or fatigue from blood loss

Causes of Abnormal Bleeding

There are a number of possible culprits if you're experiencing abnormalities in your bleeding habits.

For women who have already gone through menopause (a complete cessation of periods for 12 months or longer), vaginal bleeding could indicate cancer of the endometrium (uterine lining) or cervix. Studies show that more than 90% of women with endometrial cancer experience bleeding after menopause. (However, among all the postmenopausal women who experience bleeding, only 9% had cancer.)

During perimenopause, though, heavy bleeding may be caused by:

• Uterine fibroids or polyps
• Endometriosis
• Bleeding disorders
• Certain medications, such as blood thinners
• Pelvic infection 
• Most commonly, anovulation

Anovulation is when the ovary releases estrogen normally but doesn't release an egg. It makes the uterine lining thicken and shed in an unpredictable manner, which causes irregular and/or heavy bleeding.

A number of simple diagnostic tests, many of which are non-invasive, can determine the cause of abnormal bleeding. These include:

• Vaginal ultrasound
• Endometrial biopsy
• Hysteroscopy 

Additionally, if your healthcare provider suspects your heavy bleeding is due to a bleeding disorder or is causing anemia, they may order blood tests.

Treatment for Abnormal Bleeding

Medications, such as the birth control pill, are often the first option when it comes to treating abnormal bleeding during perimenopause. A relatively new type of intrauterine device (IUD) may also help. Marketed under the trade names Mirena and Skyla, the progestin hormone they use thins the uterine lining, which lessens the amount of lining you have to shed, while also acting as birth control.

Surgical options may be considered if medications don’t work. These include procedures such as endometrial ablation or hysterectomy.

Hysterectomy, which 600,000 American women undergo annually, is still considered the gold standard for permanently solving the problem of heavy uterine bleeding in women who aren't interested in having children. However, it's also the most invasive option.

A Word From Verywell

If you're worried about any abnormal bleeding you're experiencing, take note of the length and amount of flow and bring your concerns to your healthcare provider. If you have a family history of endometriosis or other such conditions, you may want to seek out a specialist.

Either way, don't keep quiet and assume it the problem will go away. It's better to get a diagnosis than to leave untreated something that may be serious.