Perimenopausal Bleeding: When Do I Worry?

Women in their forties often experience changes in the amount and/or frequency of their menstrual flow. This can affect lifestyle by causing fatigue and limiting activity. Some women must remain confined to home or at least within immediate proximity to a bathroom for days at a time. A woman’s mother or aunt may have had a hysterectomy for similar bleeding–raising concerns that surgery might also be in her future. We are often asked, “When do I get concerned?”

In general, menstrual cycles tend to shorten (i.e., menses get more frequent) as menopause approaches. This is a slow process occurring over the course of several years. They usually stay regular during this transition–every 23 or 24 days versus every 28-30 days previously. As the ovaries age and become less efficient, ovulation occurs less frequently. This is reflected in the menstrual cycle as a more pronounced irregularity; for example, cycles that will vary from 14-40 days or more in length. These patterns are generally hormonal and therefore benign.

Bleeding patterns that may signify a problem are those that tend to be prolonged and progressive. Prolonged meaning that the pattern persists over several months. Progressive meaning that every cycle seems to get worse, more and more heavy or perhaps longer and longer. A day or two of heavy bleeding is usually tolerable. Four or five is not. Changes such as this could signify a problem and should be discussed with your healthcare provider. The same is true for bleeding that lasts 10-12 days or more, even if light.

Your mother probably had a D&C performed to evaluate her bleeding. This approach is now considered outmoded. Nowadays a simple pelvic ultrasound usually suffices to make a diagnosis. It allows accurate identification of most pelvic pathology and allows a discussion of treatment options. And the key point here is that there are options. If you have menstrual symptoms that are worrisome, discuss them with your provider and get involved with the decisions about your care.