Perimenopausal bleeding: what’s normal, what’s not?

One of the signature symptoms of perimenopause (which typically starts in your mid 40s and lasts on average four years)¹ can be that your periods can start to become increasingly irregular and unpredictable, although this isn’t the case for all women.

Most women are already used to things that have altered their periods in the course of their life – contraception, illness, weight changes, pregnancy, stress, sometimes just a change of routine like going on holiday – and it is something of a myth that a ‘normal’ period length is 28 days with a three to five day bleed. In fact, a study carried out at University College London found that only 13% of cycles are 28 days and nearly 65% of women had cycles that lasted between 25 and 30 days². The point is a ‘normal’ bleed is what is ‘normal’ for you – whether that be a 24 day heavy cycle or a 31 day cycle with a light bleed - but it is changes to your relatively consistent cycle that can indicate you are entering the perimenopause. Whilst perimenopause is a perfectly natural stage in a woman’s life, marking the run up to the menopause and the end of her periods forever, any changes to your bleeding pattern can be disconcerting and it can be reassuring to know what you might expect at this time.

What causes irregular periods during perimenopause?

During perimenopause as your hormones begin fluctuating and ovulation (the release of an egg from one of the ovaries) becomes more infrequent levels of oestrogen and progesterone become increasing unpredictable which can result in more anarchic bleeding patterns. The time between your periods can vary from month to month and they can change in terms of becoming longer, shorter, heavier, lighter, more frequent, less frequent – or a combination of all these. This unpredictability, combined with often increased frequency and heaviness, can be difficult and tiring.

What other changes can you expect?

The colour and consistency of your period blood can provide useful information about where you are on your perimenopause and menopause transition. It can be helpful to log any changes using an app specifically designed to record personalised insights into what is happening to your body (and mind) to get a more rounded picture of what is happening to you. Things to look out for, and chart on the app, include:
Blood flow – you might see an increase, or possibly a decrease, in your menstrual blood flow. The Study of Women’s Health Across the Nation (SWAN) which involved 1320 women aged between 42 and 52 highlights these changes finding that 80% of women characterised the blood flow during their period as heavy and 90% recorded having periods that lasted longer than they did prior to perimenopause and menopause. It also highlighted that more women reported an increase in ‘spotting’ (light vaginal bleeding that happens between your period³ , typically involving very small amounts of blood and not enough for you to need sanitary protection) than before their menopause.⁴
Texture and consistency of blood – it is common to find that your menstrual blood can become thinner or thicker in consistency. This is generally due to the time it can take for blood and tissue to leave your body. If, for example, you are experiencing light bleeding your blood may seem thin or ‘watery’. If you are bleeding heavily you may notice thick, jelly-like large clots in your blood – this is your body’s way of helping you from losing excessive amounts of blood (clotting works to stop and slow bleeding). Blood can also collect and pool in your uterus when you bleed heavily so if you have been sitting or lying down for any length of time you might feel these clots pass out of your body when you stand up.
Colour changes to your period blood – light pink blood is generally seen during a lighter bleed or towards the end of your period. It also tends to signify lower levels of oestrogen, as you might expect during perimenopause. Bright red blood is usually seen when you are at the beginning of your period and/or when your flow is heavy (when it is bright red it suggests it is new and fresh blood). If your blood is a dark red this could indicate it has been sitting in the uterus for some time where it begins to darken. If your blood looks brown it is typically older and has had time to react with oxygen and oxidise leading to its darker colour. This characteristically happens at the beginning or end of your period when blood takes longer than usual to exit your body.

Understanding, and coping with, perimenopausal bleeding

Changes to your periods during perimenopause are perfectly normal in most cases but that’s not to say they are not without challenges. So, what can help?

Track your period cycle using the Health & Her Menopause App.

Log not only the length of your cycle but also what kind of bleed you are experiencing – flooding, heavy, light or somewhere in between. Chart the colour and consistency of your bleed. For example, if are you passing large clots of blood. Keeping a record of your changing menstrual cycle, alongside any other perimenopausal symptoms, should not only help you to feel personally more in control of what is happening to you, it will also provide helpful information that you can take to your GP if needed.

Speak to your close female relatives – including your mum, sisters and aunts.

Finding out what their perimenopausal period changes were like could shed some sort of light and insight into what you might expect [link to Meno and genetics page]. Sometimes the biggest help during perimenopause is simply getting confirmation that what you are going through is ‘normal’.

Be prepared.

Anticipate that your periods are becoming more anarchic and be prepared for unexpected and/or sudden bleeding by wearing period pants, panty liners, always keeping tampons or pads and a change of underwear to hand and/or wearing period pants daily. If you are bleeding heavily at night it can help to put a dark coloured towel underneath you to deal with any leaks.

Be reassured.

Erratic or irregular bleeding and changes to the colour and consistency of your period blood can understandably be concerning but the majority of time it is a completely normal part of your perimenopause journey and should not be anything to worry about.

Continue with your contraception.

If your periods are starting to become few and far between, and you can’t even remember when the last one was, it can be tempting to assume that you no longer need to worry about contraception. But if you are still ovulating you can still get pregnant and it can be helpful to be reminded that menopause is officially defined as when you haven’t had a period for a full 12 months. The generally accepted advice is that you can stop using contraception after the age of 55.⁵

Hormonal treatments could help.

Hormonal contraception and/or HRT can be effective treatments for heavy periods⁶ and can be taken continuously but be mindful of the fact that no birth control or HRT regimen method is guaranteed to be completely bleed free so spotting and irregular bleeding can be expected – generally as the result of fluctuating hormones. You may also experience spotting or unusual bleeding if your HRT is not right for you.

When to see your GP.

If changes to your bleeding start to have a negative impact on you and are getting in the way of you living your life see your GP. Let her know if you are experiencing unusually heavy bleeding⁷ -especially with large blood clots and frequent flooding (so you are having to change your tampon or pad every hour or so and/or are soaking through your bed sheets or clothes). There are a range of treatments available for heavy bleeding -known medically as menorrhagia.⁸ Similarly, if you are bleeding continuously for two weeks or more, you bleed after intercourse and/or are experiencing any bleeding that is new or is happening in between your usual cycles this should always be discussed with your GP

Take good care of yourself.

Erratic bleeding can be both physically and mentally draining so look after yourself. Find techniques to help with stress and anxiety. Rest when you need to.

Eat regularly and opt for healthy menopause-friendly foods (like those typically eaten on a Mediterranean diet).

To give you the nutrients you need, keep your blood sugar levels balanced and stop your energy from flagging further. If you are bleeding heavily and/or often you might be low in iron, or possibly deficient to the point of anaemia,⁹ so include regular amounts of iron-rich foods like lean red meat, leafy green vegetables including spinach and watercress, dried fruits, mushrooms and pulses such as lentils and chickpeas. Consuming Vitamin C-packed foods like peppers, berries and citrus fruits with the iron-rich ones will help facilitate maximum absorption of the iron. Alternatively take a supplement to ensure you are getting adequate amounts.