Vaginal bleeding during perimenopause and menopause

Menopause is associated with an end of periods, so you may be surprised to still bleed from time to time

Vaginal bleeding can occur in some women after their periods have finished and in women who take HRT.
For the vast majority of women, it does not need to be a cause for concern.
Discover when to seek advice from a healthcare professional

Ending your periods is the best benefit of menopause. But while you might expect your periods to slowly peter out during the perimenopause, and for some women they do, for others it can be an unpredictable time. A study of approximately 50,000 menstrual cycles of women aged 42–52 years found it was common for perimenopausal women to experience: bleeding durations of 10 days or more (77% of women reported this on at least three occasions); spotting of six or more days; or three or more days of heavy bleeding [1].

Bleeding can vary tremendously between women in terms of frequency, duration and amount, and factors such as race/ethnicity and BMI can have an influence – the same study found African-American women were more likely to experience heavier bleeding than white, Chinese, or Japanese women.

There are many reasons why bleeding occurs. Firstly – and forgive the obvious statement – make sure it is definitely coming from your vagina and not your anus, as this can be mistaken and rectal bleeding has significantly different causes and treatments.

Vaginal bleeding can be triggered by a structural cause such as fibroids or polyps, or by overgrowth of the cells lining your uterus but for most women, vaginal bleeding is due to hormonal changes. During perimenopause, your oestrogen levels can have greater fluctuations throughout the month and when there are high levels or fluctuating levels of oestrogen, bleeding can occur.

RELATED: Fibroids and the menopause

Bleeding on HRT

If you are taking HRT, you may be using a type of HRT known as sequential HRT, which allows for a ‘withdrawal’ bleed. You may notice some bleeding at other times when it was not scheduled to happen.

Alternatively, your periods may have already stopped, and you take continuous HRT. This means you don’t usually have any bleeding, but you might on occasions find that you still do.

Either way, bleeding on HRT can be common and affect up to 40% of users [2]. Many women experience unscheduled bleeding or spotting within the first three months of starting HRT, or changing the dose or type of HRT. This is a normal part of your body adjusting to the new hormone doses. Even after the initial adjustment period, some women may continue to experience irregular bleeding. It is important to monitor this and discuss any concerns with your healthcare professional. If you experience heavy or persistent bleeding, it is crucial to consult your clinician to rule out any underlying issues and adjust your treatment if necessary.

It is likely your clinician will recommend that you have an examination and also an ultrasound test to assess the thickness of the lining of your womb and see if there is an underlying structural reason for the bleeding. Your healthcare professional may also recommend other investigations.

Is there any treatment and when should I seek help?

Managing vaginal bleeding whilst taking HRT involves several strategies, depending on the underlying cause and the type of HRT being used.

Common approaches include:

Adjusting hormone doses – One of the first steps is to review the balance of oestrogen and progesterone in your HRT regime. Progesterone helps to stabilise the lining of the womb, preventing it from becoming too thick which can lead to heavy bleeding. Your clinician might recommend changing your progesterone dose or even the way you take it (using progesterone vaginally can sometimes reduce bleeding more effectively than taking it orally).
Changing HRT types – sometimes changing the type of HRT you take can make a difference. This might involve taking progesterone for a longer part of your cycle, such as 25 days out of a 28-day cycle, instead of just 14 days, or taking every day. Or a change in the type of progesterone you take may be considered.
Changing the delivery method – one option may be to consider using a hormone coil such as Mirena which delivers a synthetic progesterone directly to the womb lining and can significantly reduce bleeding.

The aim of this is to try to get the right balance of oestrogen and progestogen for you individually, and this can sometimes take a few months to optimise. If this still doesn’t help reduce the bleeding, it might be suggested that you have an assessment of the lining of your womb by a gynaecologist, to see if there is any other reason (apart from hormonal) to explain the bleeding.

If you still have periods, remember that during perimenopause they can become more erratic, closer together, further apart, heavier or lighter in flow, and this is normal.

However, if you are bleeding in ways that do not seem like a period, or you are menopausal and have since started bleeding again (and don’t take HRT) speak to your doctor or nurse about it.

Top tips for coping with vaginal bleeding

Keep a note of it
An accurate record of when the bleeding happens, how long it lasts for and how heavy it is, will be very useful information for your doctor or nurse to understand the problem. The Periods section in the Journal area of the free balance app (balanceapp.com) is designed with this in mind. RELATED: A guide to period tracking
Tell your healthcare professional
Don’t suffer in silence, there are often ways to reduce the bleeding. If you are not taking HRT and the bleeding is not typical for you, especially if it is prolonged, you should see a healthcare professional.
Look at your HRT
It is extremely common to bleed during the first three to six months of taking HRT. If it hasn’t settled after this time, many women find that altering the dose or type of oestrogen and progesterone – or the way it is taken – usually helps minimise any bleeding.
Wear period pants
Period pants – these are not just the worst knickers in your drawer – are great for coping with unexpected bleeding. The leakproof underwear absorbs and wicks away liquid to keep you dry and comfortable throughout the day. They can usually cope with around two regular tampons’ worth of blood/discharge and you just put them in the wash with your usual load. As well as being a more environmentally friendly option than liners, pads or tampons, they can give you peace of mind when you’re out and about.

RELATED: Changes in bleeds: your FAQ

References