Heavy Period During Perimenopause? Here’s What’s Normal

For decades, your period has shown up (mostly) as expected. But as you enter perimenopause, the often long and snakey road to menopause, your periods may get wonky. They may skip a month or come a bit early, and there may be no such thing as typical: One month might be a pad-plus-frequently-changed-super-plus deluge, the next a panty liner is enough. 

“The bleeding associated with perimenopause can vary from light to normal to heavy,” says Nathan Goodyear, M.D., medical director of Brio-Medical in Scottsdale, AZ. But even if you’re aware that perimenopause periods can be heavier than normal, there’s heavy, and then there’s Hurricane Sandy flooding level heavy.

How Perimenopause Changes Your Period

So when should you worry about perimenopausal bleeding? What if you’re emptying a menstrual cup multiple times a day, or changing a tampon once an hour? What if you have been doing so for days, or if you’ve had perimenopause bleeding for three weeks?  Or what if you haven’t had any bleeding in several months? It can feel scary. “Each month may be dramatically different from the month before,” says Jim Staheli, D.O., Medical Director for Broad Health, Hone Health’s affiliated practice, and a family medicine doctor in Atlanta, GA.

About the Experts

Nathan Goodyear, M.D., is the medical director of Brio-Medical, a holistic, integrative healing center in Scottsdale, AZ. In addition to being board-certified in obstetrics and gynecology, Dr. Goodyear is a Fellow in Functional and Regenerative Medicine.

Jerilynn Prior, M.D., is a professor of endocrinology at the University of British Columbia, in Vancouver, Canada who focuses on, among other things, the menstrual cycle and the study and treatment of vasomotor symptoms.  

Jim Staheli, D.O. is the medical director of Broad Health, Hone Health’s affiliated practice. He specializes in metabolic and nutritional medicine, anti-aging, and functional medicine.

Other things that may happen due to your hormones not rolling out as usual:

Periods showing up whenever they feel like it

 “If there’s one word that could describe the menstrual pattern women experience during perimenopause it would be irregular,” says Staheli. Noticing a longer stretch between periods is very common, due to delayed ovulation. You might also skip a month or two, because you don’t ovulate at all or because the lining of your uterus didn’t get the progesterone lift to put it into prepper mode. You might resume a monthly period rhythm for a bit—and then not have a period again for a few months.

Spotting between periods

A small enough amount of blood between periods that doesn’t require a pad or tampon is considered spotting. It’s usually due to a buildup of the lining of your uterus between periods, thanks, again, to your fluctuating hormones.

Super light bleeding

Some months your period can be almost as non-existent as spotting. When estrogen or progesterone levels are very low, your period may be extremely light and only last a few days.

Super heavy bleeding

Many women search Google for “heavy periods at 50,” which makes sense, since the average age of menopause is 51, and periods during perimenopause may well be heavy. Heavier than pre-perimenopause can be normal if your ovulation that month doesn’t happen on schedule. But there is such a thing as too heavy. “Bleeding patterns which are prolonged, greater than seven days, and which occur more frequently than every 28 days, or two weeks, should be followed up with your physician,” says Goodyear. (More on what these things may be, below.)

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What Causes Heavy Perimenopause Periods?

The official unofficial motto for the menopause transition is Expect the Unexpected (you know there are t-shirts on Etsy). That applies to perimenopause bleeding as much as other symptoms like hot flashes. But what causes heavier bleeding?

Estrogen changes

As levels of estrogen fluctuate and ovulation becomes unpredictable, so will your periods. 

Before perimenopause, follicle stimulating hormone (FSH) rises in the first two weeks of your period, and luteinizing hormone (LH) helps to trigger ovulation. But in perimenopause, “the normal signaling patterns which dominate and control the follicular and luteal phases of the menstrual cycle are absent,” says Goodyear. 

This can cause several changes, one of which may be that you don’t ovulate on schedule, and the wall of your uterine lining builds up for longer than usual. That often results in a cycle length of 45-plus days, compared to the normal 28-day cycle, he says. Oh, and a heavy period during perimenopause.

Progesterone changes

If progesterone levels dip below estrogen during perimenopause, your uterine lining may thicken more than usual, leading to a heavier period. Low progesterone can also cause you to have a delayed or totally skipped period, which means the lining has a longer time to develop before it sheds.

When to Worry About Perimenopausal Bleeding

So if there is no “normal” anymore, what warrants a chat with your doctor? Staheli says you should call your doctor if:

• Bleeding is excessive: You soak a pad or tampon every one to two hours, the deluge lasts  more than four hours, or you need to empty your menstrual cup more than what’s recommended on the box
• You pass clots larger than a quarter
• A period drags on for more than two weeks
• You have bleeding or spotting after sex
• Spotting or light bleeding becomes persistent between periods
• Your sleep is interrupted by having to change a pad or empty a menstrual cup (or because you are bleeding through to your clothes and bedding).

If prolonged and/or heavy bleeding is accompanied by symptoms like dizziness, shortness of breath, fatigue, or an irregular heartbeat, be sure to share those with your doctor as well. They can help to flag another underlying health issue that could be causing or contributing to your heavy or frequent bleeding. 

Other causes for irregular periods

What else could be causing worrisome bleeding during perimenopause? There are a few things, depending on what’s going on with your periods. 

• Other hormones that are out of balance. Thyroid disorders including hypothyroidism (underactive thyroid) and hyperthyroidism (overactive thyroid) as well as issues with the pituitary gland (the pea-sized gland at the base of the brain that controls a number of hormone systems) can all cause heavy periods, according to Cleveland Clinic. 
• Certain benign conditions. Abnormal bleeding can also be brought on by polyps and endometrial hyperplasia (a condition where the lining of the uterus grows too thick), according to the Mayo Clinic.
• A more serious issue. Spotting and light bleeding between periods can be a symptom of uterine cancer, the most common gynecological cancer in the U.S., according to the CDC. And for women with certain confounding health issues, the risk of uterine cancer is higher, says Goodyear. People who carry a lot of body weight, or have an autoimmune disease, he says, are of higher risk. If you and your practitioner are concerned about cancer, your doctor may recommend testing that could include a pelvic ultrasound, biopsy, or another procedure.

Tips for Managing Perimenopausal Bleeding

Keeping notes in a journal or period app can help you track when they start, how long they last, and how heavy they are. (Be sure to note accompanying symptoms, like dizziness or fatigue.) If anything warrants a talk with your doctor, you’ll have the info easily at hand. 

A few other tools at your disposal for heavy periods during perimenopause:

Carry a stash

Keeping pads and pantyliners in your purse, and/or wearing period underwear can help you manage surprise periods and unexpectedly heavy flows. Try reusable pads or a menstrual cup to help keep costs down.

Take care of your health

Eating well, exercising daily, managing stress, and getting enough sleep, can go a long way to helping you cope with all the uncertainty of inconsistent or heavy perimenopausal bleeding, says Staheli. Foods that include iron and vitamin C like broccoli or oranges can balance any vitamin deficiencies.

Take pain medications

Your doctor may prescribe an anti-inflammatory medication, magnesium, or suggest an over-the-counter pain reliever (particularly if you are dealing with cramping or other PMS-like symptoms), says Staheli.

Consider iron supplements

Talk to your doctor about getting your levels tested before starting to take these, but if your periods are very heavy, you might be anemic.

Stay hydrated

Heavy periods during perimenopause can impact the total amount of blood flowing through your body. By drinking more water (four to six more glasses a day), you’ll ensure a healthy level of blood and might reduce other inconvenient symptoms like headaches or bloating.

Ask about prescription medications

Several types of medications can reduce bleeding, including tranexamic acid and gonadotropin-releasing agonists, according to Mayo. Taking a combined oral contraceptive pill is another option you can discuss with your doctor. “It can perform the dual role of providing contraception while reducing symptoms and maintaining bone strength,” says Staheli. (Keep in mind that until you officially hit menopause–which means a full year with no periods–there is always a chance of getting pregnant!) And, the pill also comes with increased risks of stroke and breast cancer. 

Prescription medications can also include bioidentical progesterone to balance out the estrogen excess and flux, but blood work can help assess which approach may be best for you. Talk to your practitioner to figure out your best options.