Is Irregular Vaginal Bleeding During Perimenopause and Menopause Normal?

So, you packed away the tampons and pads, thinking those monthly visits were finally over—until suddenly, bleeding! Cue the sighs, eye rolls and perhaps some cursing.

You’re not alone. Millions of women have experienced irregular vaginal bleeding during and after menopause. (I’m one of them.) While this is quite common, any unexpected bleeding warrants prompt* evaluation to rule out any serious conditions.

(*By prompt, I mean within the month, although this is not written in stone. It could be within a few weeks, but definitely not “It can wait until next year’s gyn visit” either. And it’s not a “I need to go to the ER today” unless the bleeding is hemorrhage level.)  

Regardless, this situation can feel concerning and scary, though the vast majority of cases won’t be serious. Here’s what might be causing your unexpected visitor:

Perimenopausal Bleeding

The 4-8 year transitional phase before your body enters menopause—known as perimenopause—can be intense on your body.

During this phase, your ovaries produce less estrogen, but the decline isn’t always steady. Instead, hormonal levels fluctuate dramatically. This hormonal roller coaster can lead to irregular periods, spotting, or heavier-than-usual bleeding.

It can also make existing uterine fibroids (non-cancerous muscle growth in your uterus) or polyps (tissue attached to the inner wall of your uterus) grow larger, triggering more bleeding.

Postmenopausal Bleeding (PMB)

Once those 4-8 years close out, you’re on to the next phase: Menopause. At this point, once you’ve stopped getting your period for a year straight, any vaginal bleeding is considered “abnormal.”

But irregular bleeding does happen! Here’s what might cause it:

1. Thinning Tissue: The most common cause (up to 60% of cases) is that your vaginal and uterine tissues have simply become thinner and more fragile due to lower estrogen levels. This condition makes tissues more prone to bleeding from minor irritation, which is why some women bleed after sex!
2. Growth in the Uterus: This includes harmless polyps, but it could also be the more harmful endometrial hyperplasia (the abnormal thickening of the uterine lining).
3. Endometrial Cancer: While less common (only up to 10% of cases), this type of uterine cancer is why doctors take postmenopausal bleeding seriously.
4. Changing Dose or Timing of Hormone Replacement Therapy: If you are on HRT and miss a dose, start or stop pills, bleeding can occur. This is common.  

How Do I Know If My Bleeding Is “Normal?”

Before seeing your OBGYN, there are a few details you’ll want to gather:

• Color: Is it dark brown (older blood) or bright red (fresh blood)?
• Cramps: Are you cramping with the bleeding?
• Source: Is the blood coming from the vagina? I know it sounds obvious, but trust me—it sometimes isn’t. Insert a tampon to be sure.
• Pattern: Does it stop and start? Or is it a heavier flow?
• Amount: Is it just a few spots or enough to need a pad?
• Hormones: If you’re on any hormones, did you miss any doses?

What Your Doctor Will Do

Usually, your doctor will administer an ultrasound to measure your uterine lining thickness. If it’s less than 4mm, the cancer risk is low. But if it’s thicker than 5mm (or if ultrasound results are inconclusive)? Your doctor will recommend an endometrial biopsy to obtain tissue samples for further analysis. This biopsy can be done:

1. In an office (with some cramping).
2. In an operating room under anesthesia.

If you’re a woman who is many years post menopause or whose never given birth vaginally, there’s a chance your cervix will be tighter. So, for safety (and comfort!) reasons, you’ll probably be recommended the latter.

Types of Treatment

Based on what’s causing your bleeding, treatment might look like:

• Thinning Vaginal Tissue (Atrophic Vaginitis) ➜ Topical estrogen therapy, such as creams, rings, or tablets inserted directly into the vagina.
• Polyps or Fibroids ➜ In some cases, surgical removal (such as a hysteroscopy, which uses a camera to see and remove growths).
• Endometrial Hyperplasia ➜ Progestin therapy (pills, shots, or IUD to thin out the lining) or surgical interventions such as dilation and curettage (D&C).

In short, during perimenopause, irregular bleeding episodes are pretty normal. However, if you’ve already been period-free for 12 months straight and then notice bleeding, it could be time to investigate.

While most cases won’t be serious, prompt check-ups ensure that if something is amiss, you’ll catch it early when treatment options are simpler and more effective. Until then, it might be worth it to keep those “Just in case” tampons around a little longer!