Perimenopause Irregular Periods

During the transition, the ovaries release eggs less regularly and hormone production becomes uneven. Cycles may first shorten, then become more variable. Later, a long gap may be followed by another period. The amount of bleeding can be lighter or heavier than before.

Cycle length runs from the first day of one period to the first day of the next. Bleeding duration is the number of days you actually bleed. Recording both helps distinguish a longer cycle from a longer period.

The STRAW+10 staging system describes the early transition using a recurring difference of at least seven days between consecutive cycle lengths. A gap of at least 60 days marks the late transition in that system. These are staging patterns, and abnormal bleeding still needs clinical assessment.

If your cycles were already irregular, or hormonal contraception changes your bleeding, tell the clinician. Your previous pattern and medication affect how much information the new bleeding provides.

You can ask for help when bleeding disrupts sleep, work, exercise, or leaving home, even if you are unsure how to describe the amount. Explain how often you change protection and whether you use two products at once or need to change overnight.

Fibroids, polyps, adenomyosis, infection, thyroid disease, and medication can cause abnormal bleeding. Pregnancy-related causes are also considered when pregnancy is possible. Changes in the uterine lining may require investigation, particularly with persistent bleeding or relevant risk factors.

Heavy or prolonged bleeding can cause iron deficiency anemia. Symptoms may include fatigue, weakness, dizziness, headaches, and shortness of breath. Tell the clinician if the bleeding change has been followed by tiredness or a reduced ability to exercise.

Hormonal contraception and hormone therapy can also alter bleeding. Bring the product, dose, schedule, start date, and any missed doses. This helps establish whether the bleeding fits the medication pattern or needs further investigation.

The clinician asks about period dates, bleeding amount, pain, pregnancy possibility, medication, and your medical history. Depending on the situation, assessment may include an examination, pregnancy test, blood count, or thyroid tests.

A pelvic ultrasound can help assess fibroids, polyps, and other structural causes. An endometrial biopsy takes a small sample of the uterine lining for examination. Hysteroscopy uses a thin camera to view the inside of the uterus. The choice depends on your age, bleeding pattern, and risk factors.

Routine menopause hormone testing often adds little when someone aged 45 or older has typical symptoms. The investigation of bleeding has its own purpose: identifying a cause and selecting treatment. Ask why a proposed test is needed and how the result will affect the plan.

• Bring several months of period dates if you have them.
• Record bleeding days, clots, pain, and spotting between periods or after sex.
• List medication, contraception, and supplements, including recent changes.
• Mention dizziness, fatigue, breathlessness, or a possible pregnancy.

Hormonal options

For eligible women, combined hormonal contraception can lighten flow and make bleeding more predictable. Progestin-only methods and a levonorgestrel IUD may also reduce bleeding. The choice depends on the cause, medical history, and whether you need pregnancy prevention.

Nonhormonal medication

Tranexamic acid is a prescription taken during periods to reduce heavy bleeding. NSAIDs, such as ibuprofen, can help some women with flow and cramps. A clinician should check suitability, other medicines, and conditions such as clotting problems, stomach disease, or kidney disease before recommending treatment.

Procedures for persistent bleeding

When medication is insufficient or a structural cause needs treatment, options may include removal of a polyp, fibroid treatment, endometrial ablation, or surgery. Future pregnancy plans matter. Pregnancy after endometrial ablation can have serious risks, so contraception remains necessary.

If blood loss has caused anemia, the plan should address both iron replacement and the bleeding source. Discuss the dose and follow-up of any iron treatment with the clinician.

Ovulation can still happen during perimenopause, including after several missed periods. Continue an appropriate contraceptive method if pregnancy is possible and you want to prevent it. Ask when it can safely be stopped, particularly if medication masks bleeding.

Natural menopause is confirmed after 12 consecutive months without a period, once other causes have been excluded. Bleeding after that point requires an assessment. If you are using hormone therapy, ask which bleeding pattern is expected for your regimen and when unscheduled bleeding should be reported.

NICE recommends prompt assessment of unscheduled bleeding that continues beyond the first six months of systemic hormone therapy or beyond three months after a dose or product change. Heavy bleeding or other concerning symptoms may need review sooner.