Gynecologic Problems
FAQ162, November 2018



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Perimenopausal Bleeding and Bleeding After Menopause

What are menopause and perimenopause?

Menopause is the time when a woman’s menstrual periods stop permanently. Menopause is confirmed after 1 year of no periods. The average age of menopause is 51 years, but the normal range is 45 years to 55 years.

The years leading up to this point are called perimenopause. This term means "around menopause." This phase can last for up to 10 years. During perimenopause, shifts in hormone levels can affect ovulation and cause changes in the menstrual cycle.

What are some of the common changes that occur in the menstrual cycle during perimenopause?

During a normal menstrual cycle, the levels of the hormones estrogen and progesterone increase and decrease in a regular pattern. Ovulation occurs in the middle of the cycle, and menstruation occurs about 2 weeks later. During perimenopause, hormone levels may not follow this regular pattern. As a result, you may have irregular bleeding or spotting. Some months, your period may be longer and heavier. Other months, it may be shorter and lighter. The number of days between periods may increase or decrease. You may begin to skip periods.

How can I tell if bleeding is abnormal?

Any bleeding after menopause is abnormal and should be reported to your health care professional. Although the menstrual period may become irregular during perimenopause, you should be alert for abnormal bleeding, which can signal a problem not related to perimenopause. A good rule to follow is to tell your health care professional if you notice any of the following changes in your monthly cycle:

  • Very heavy bleeding
  • Bleeding that lasts longer than normal
  • Bleeding that occurs more often than every 3 weeks
  • Bleeding that occurs after sex or between periods

What are some of the common causes of abnormal bleeding?

  • Polyps—Polyps are usually noncancerous growths that develop from tissue similar to the endometrium, the tissue that lines the inside of the uterus. They either attach to the uterine wall or develop on the endometrial surface. They may cause irregular or heavy bleeding. Polyps also can grow on the cervix or inside the cervical canal. These polyps may cause bleeding after sex.
  • Endometrial atrophy—After menopause, the endometrium may become too thin as a result of low estrogen levels. This condition is called endometrial atrophy. As the lining thins, you may have abnormal bleeding.
  • Endometrial hyperplasia—In this condition, the lining of the uterus thickens. It can cause irregular or heavy bleeding. Endometrial hyperplasia most often is caused by excess estrogen without enough progesterone. In some cases, the cells of the lining become abnormal. This condition, called atypical hyperplasia, can lead to cancer of the uterus. When endometrial hyperplasia is diagnosed and treated early, endometrial cancer often can be prevented. Bleeding is the most common sign of endometrial cancer in women after menopause (see FAQ147 Endometrial Hyperplasia).

How is abnormal bleeding diagnosed?

To diagnose the cause of abnormal perimenopausal bleeding or bleeding after menopause, your health care professional will review your personal and family health history. You will have a physical exam. You also may have one or more of the following tests:

  • Endometrial biopsy—Using a thin tube, a small amount of tissue is taken from the lining of the uterus. The sample is sent to a lab where it is looked at under a microscope.
  • Pelvic ultrasound—Sound waves are used to create a picture of the pelvic organs with a device placed on the abdomen or in the vagina.
  • Sonohysterography—Fluid is injected into the uterus through a tube, called a catheter, while ultrasound images are made of the uterus.
  • Hysteroscopy—A thin, lighted tube with a camera at the end, called a hysteroscope, is inserted through the vagina and the opening of the cervix. The hysteroscope allows the inside of the uterus to be seen.
  • Dilation and curettage (D&C)—The opening of the cervix is enlarged. Tissue is scraped or suctioned from the lining of the uterus. The tissue is sent to a lab, where it is examined under a microscope.

Some of these tests can be done in your health care professional’s office. Others may be done at a hospital or surgical center.

What treatment is available for abnormal bleeding?

Treatment for abnormal perimenopausal bleeding or bleeding after menopause depends on its cause. If there are growths (such as polyps) that are causing the bleeding, surgery may be needed to remove them. Endometrial atrophy can be treated with medications. Endometrial hyperplasia can be treated with progestin therapy, which causes the endometrium to shed. Thickened areas of the endometrium may be removed using hysteroscopy or D&C.

Women with endometrial hyperplasia are at increased risk of endometrial cancer. They need regular endometrial biopsies to make sure that the hyperplasia has been treated and does not return.

Endometrial cancer is treated with surgery (usually hysterectomy with removal of nearby lymph nodes) in most cases. Discuss your options with your health care professional.

Glossary

Cervix: The lower, narrow end of the uterus at the top of the vagina.

Endometrium: The lining of the uterus.

Estrogen: A female hormone produced in the ovaries.

Hormone Therapy: Treatment in which estrogen and often progestin are taken to help relieve symptoms that may happen around the time of menopause.

Hysterectomy: Surgery to remove the uterus.

Lymph Nodes: Small groups of special tissue that carry lymph, a liquid that bathes body cells. Lymph nodes are connected to each other by lymph vessels. Together, these make up the lymphatic system.

Menopause: The time when a woman’s menstrual periods stop permanently. Menopause is confirmed after 1 year of no periods.

Menstrual Periods: The monthly shedding of blood and tissue from the uterus.

Ovulation: The time when an ovary releases an egg.

Perimenopause: The time period leading up to menopause.

Progesterone: A female hormone that is made in the ovaries and prepares the lining of the uterus for pregnancy.

Progestin: A synthetic form of progesterone that is similar to the hormone made naturally by the body.

Uterus: A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus.

If you have further questions, contact your obstetrician–gynecologist.

FAQ162: This information was designed as an educational aid to patients and sets forth current information and opinions related to women’s health. It is not intended as a statement of the standard of care, nor does it comprise all proper treatments or methods of care. It is not a substitute for a treating clinician’s independent professional judgment. Please check for updates at www.acog.org to ensure accuracy.

Copyright November 2018 by the American College of Obstetricians and Gynecologists

American College of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188
Mailing Address: PO Box 96920, Washington, DC 20024-9998