Irregular Bleeding: 7 Ways Your Period Can Change in Perimenopause

You may have expected your period to change or slow down during perimenopause, but many women are blindsided by exactly how it changes.

"My period came twice this month." "I haven't had a period in three months." "I've been bleeding for nearly three weeks." These are all different, yet common experiences of irregular periods in perimenopause. None are anyone’s fault, and they all can have solutions.

Menstrual irregularities are one of the most common signs of perimenopause, but they may also be one of the most misunderstood.

As hormone levels change, you’re likely to see your period change, too. But just because something’s different and you’re in perimenopause doesn’t mean it’s no big deal or even that you have to live with it. Here, we explain the period changes you may experience and why, as well as the signs you should seek medical care for your menstrual changes.

How Perimenopause Changes Your Menstrual Cycle

Perimenopause is all about your period changing and eventually ending. In fact, most experts define it as the time of menstrual change before your last period, as well as the 12 months after. In most cases, once you’ve been naturally period-free for a full year, you’ll be in menopause.

“I often describe perimenopause as the mirror image of puberty,” says Dr. Mary Claire Haver, a board-certified OB-GYN, Certified Menopause Practitioner and author of The New Perimenopause.  “Just as hormones fluctuated on the way into our reproductive years, they fluctuate on the way out."

During perimenopause, several major shifts happen that can affect your period. Your body will likely produce less of the hormone progesterone. The hormone estrogen will likely decline overall, too, but it can fluctuate to higher and lower levels. Ovulation (the release of an egg by an ovary) is likely to happen less often and at irregular intervals. As ovulation becomes inconsistent, the perimenopause period does, too.

"If there's one symptom that catches women off guard during perimenopause, it's how dramatically their periods can change,” Dr. Haver. “Cycles that were predictable for decades may suddenly become shorter, longer, heavier, lighter, or disappear altogether."

What Counts as an Irregular Period in Perimenopause?

Abnormal uterine bleeding (AUB) is a term clinicians use for bleeding that falls outside of typical menstrual cycle timing, frequency, duration, and/or volume of flow. Typical pre-perimenopause cycles last about 24 to 38 days, with menstruation lasting four-and-half to eight days, and 5-80 milliliters of blood loss.

Due to the hormone fluctuations and irregular ovulation that happen during perimenopause, your period may become irregular overall or just different from what you’re used to. Both are worth mentioning to your doctor, according to The Menopause Society. It may help to track your period on a calendar or app and provide the information to your doctor for evaluation.

It’s important to note that you may see any bleeding as a "period," but medically, a true menstrual period follows ovulation. During perimenopause, ovulation becomes inconsistent, so you may experience bleeding that isn’t technically a menstrual cycle.

You may notice your periods during perimenopause become more and more irregular as you near menopause.

7 Common Period Changes During Perimenopause

These are a few perimenopause period changes women can experience:

1. Heavy bleeding in perimenopause

Progesterone regulates the uterine lining (endometrium) during each menstrual cycle. As progesterone levels are reduced, the lining can become thicker before it sheds, causing a heavier period.

You likely don’t have to measure the volume of your perimenopause period to know that it’s heavier than usual. Let your doctor know if you notice this change, especially if it’s affecting your quality of life. It could just be a symptom of perimenopause but it could also cause an issue like iron-deficiency anemia or be a sign of another problem. Gushing blood when you stand or sit up or passing large blood clots are also signs you should be evaluated. When bleeding is excessive, it’s important to have intervention to prevent further blood loss.

2. Lighter periods

A lighter period can also happen due to hormone shifts that affect the uterine lining. Know that a light period can be mistaken for spotting, which could be a sign of pregnancy. If you have any concern, see your doctor for an evaluation.

3. Period every two weeks

Shorter cycles can happen during typical perimenopause. But it might be hard to tell whether or not you’re experiencing a period or bleeding between periods. Notify your doctor if you’re bleeding every two weeks to be sure.

4. Late periods

Your menstrual cycle could also lengthen during perimenopause. At this time, you may ovulate less often, and so your periods may happen less frequently, too. This may be more likely to happen as you near menopause.

5. Missed periods

A missed period often happens because the ovary didn’t release an egg that month. This may be more likely to happen as you near menopause, at which time you could skip 60 days or more between periods. While it could be a normal stage on the road to menopause, you should always tell your doctor so they can evaluate you.

6. Spotting between periods

Bleeding or spotting more frequently than usual may mean that you’re having shorter cycles due to the hormone fluctuations of perimenopause. But it could also be a sign of another issue. Let your doctor know about your spotting, especially if it’s happening after sex, you could be pregnant, or you’re having other symptoms.

7. Bleeding for weeks

It’s common for periods to become longer as you get closer to menopause. How long exactly can vary from person to person. (Some may see perimenopause bleeding for 3 weeks or longer.) If your bleeding has been going on for more than a week, it’s important to get checked out to rule out an issue and to prevent problems such as iron-deficiency anemia.

Why Bleeding Isn't Always "Just Perimenopause"

While the period changes you’ve experienced during perimenopause are likely normal, it’s always important to keep your doctor informed about what’s going on. They can evaluate you for underlying causes that may give you answers to why you’re experiencing perimenopause period changes.

“Hormone fluctuations are a common cause of irregular bleeding during perimenopause, but they aren't the only cause,” says Dr. Haver. “Before we assume it's simply perimenopause, we need to rule out other conditions that may require treatment.”

Doctors generally use two categories of causes that help them diagnose and manage abnormal uterine bleeding:

Structural causes of irregular bleeding: 

Sometimes, problems with the uterus can cause irregular bleeding in perimenopause.

• Fibroids are benign tumors that can lead to heavy or prolonged menstrual bleeding.

• Polyps are growths of tissue that can form in the cervix or inside the uterus. They can cause bleeding between periods. Most are benign. 

• Adenomyosis is when endometrial tissue is inside the uterine muscle. It can lead to heavy, painful or prolonged periods.

• Precancerous changes. In rare cases, unpredictable bleeding can be a sign of cancer. 

Functional or hormonal causes of irregular bleeding: 

Certain health conditions or medications can also cause irregular bleeding in perimenopause:

• Irregular ovulation. Ovulatory conditions, such as Polyendocrine Metabolic Ovarian Syndrome (PMOS) and thyroid disorders, can affect ovulation, leading to less frequent, irregular, heavy, or prolonged periods.

• Endometrial issues happen and affect the endometrium’s ability to control bleeding.

• Medications, such as hormonal birth control and anticoagulants can cause abnormal bleeding.

• Bleeding disorders can also cause heavy periods.

Your doctor can evaluate you to be sure your irregular bleeding is a typical perimenopause symptom and not another issue.

When to See Your Doctor About Irregular Bleeding

Annual well-visits with your gynecologist or primary care doctor are important. During those visits, bring up any symptoms or changes you’re experiencing. There’s likely an explanation that can help you know exactly how to manage your bleeding.

And don’t hesitate to see your doctor right away if anything concerns you. Symptoms that warrant prompt evaluation include:

• Spotting or bleeding after sex

• Bleeding between periods

• Soaking through pads or tampons, or filling a menstrual cup, every hour

• Passing clots the size of a quarter or larger

• Bleeding lasting more than a week

• Severe pelvic pain

• Bleeding after experiencing menopause

• Sudden, severe bleeding

• Gushing or flooding blood when you stand or sit up

• Heavy bleeding with other symptoms, such as chest pain, shortness of breath, lightheadedness, or dizziness. (Seek emergency care.)

• Symptoms of iron-deficiency anemia, such as fatigue, impaired cognition, low mood, sleep problems, and headaches

How Doctors Evaluate Abnormal Bleeding

If you’re evaluated by your clinician for abnormal bleeding during perimenopause, their first goal will be to rule out serious causes. If there’s an underlying condition that’s causing the changes, it’s likely benign and treatable.

The evaluation will likely include asking you about your health history and any medications you’re taking. If you’ve been tracking your period and symptoms, bring the information you’ve gathered to your appointment. You may also be given a pregnancy test if appropriate.

During the visit, the doctor will likely perform a pelvic exam with a pap test, and you may receive bloodwork and/or an ultrasound depending on your symptoms. Additional testing, such as endometrial biopsy could be performed as well.

If there’s no underlying issue, then your period changes may simply be a product of perimenopause.

Treatment Options for Irregular Perimenopause Bleeding

Your doctor will go over your treatment options for irregular perimenopausal bleeding based on your symptoms and how they’re affecting you. There is a range of evidence-based options available that can help you manage symptoms. This could include the following.

Expectant management

If your irregular bleeding isn’t due to an underlying problem causing you a health issue, like iron-deficiency anemia, and isn’t affecting your quality of life, you may decide to adopt a wait-and-see approach. This means you and your doctor choose not to pursue treatment at this time but can adjust if things change.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Taking an NSAID such as ibuprofen, naproxen, or mefenamic acid as directed by your doctor may reduce bleeding by 10% to 15%, according to studies.

Tranexamic acid

An oral dose of tranexamic acid taken every eight hours for five days may reduce blood loss by 26% to 52%, according to studies. This may be another helpful option for people who don’t want to use hormonal treatments.

Combined hormonal birth control

A combined estrogen-progesterone birth control pill can help regulate ovulation and reduce blood loss.

Progestin therapy

A progesterone-only pill or monthly injection is also an option for some women. This can be prescribed at a low-dose to reduce bleeding.

Dr. Haver notes that traditional menopausal hormone therapy (MHT) helps treat hot flashes, sleep disruption, mood changes, and bone health, but it is not intended to regulate menstrual bleeding. Women whose primary concern is abnormal bleeding often require different therapies specifically designed for cycle regulation.

Levonorgestrel-releasing IUD

If your abnormal bleeding is chronic, your doctor may recommend an IUD that releases a synthetic progestin hormone called levonorgestrel. Some types of this IUD can reduce blood loss by 71% to 95% and can be used for up to five years.

Dilation and cutterage (D&C)

If other treatments don’t work well for you, surgery may be an option. A D&C removes tissue from the lining of the uterus. It may help reduce menstrual bleeding, especially if you have clots on your uterine lining.

Endometrial ablation

In this surgery, the uterine lining is destroyed. Endometrial ablation is not recommended if you want to become pregnant in the future and can be an alternative to a hysterectomy.

Hysterectomy

A hysterectomy is surgery to remove all or part of the uterus. It also prevents any future pregnancies and is considered a complete solution to end abnormal uterine bleeding.

A hysterectomy can be an appropriate treatment for certain uterine conditions, but it’s not a treatment for perimenopause itself, says Dr. Haver. Hysterectomy should only be performed following a clear diagnosis and a thoughtful discussion of risks, benefits, alternatives, and future health considerations.

Can You Still Get Pregnant During Perimenopause?

Yes, you can get pregnant during perimenopause. Ovulation becomes unpredictable, but still happens. In fact, it may be harder to know exactly when you’ll ovulate if your periods become more irregular.

If you don’t want to become pregnant, continue using contraception until your doctor confirms you’ve gone through menopause

Frequently Asked Questions