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Heavy menstrual bleeding during perimenopause
What's “normal” and when to get help
Top things to know about heavy bleeding during perimenopause:
Many people notice heavier bleeding during perimenopause
Medical treatments and lifestyle changes can help manage this
If you notice any bleeding after menopause, it’s important to talk to your healthcare provider
Tracking with Clue Perimenopause mode can help you notice patterns and learn what’s typical for you
What is perimenopause?
Perimenopause is the transition before menopause, when the ovaries gradually stop producing estrogen (1,2). Menopause is defined as 12 straight months without a period (1). Most people experience menopause between the ages of 45 and 55, and on average, at around age 51 to 52 (1–4).
During perimenopause, estrogen levels fluctuate (2). This usually happens for most people during their 40s, but it can start earlier or later for some (2). One of the most common signs of perimenopause is a change in menstrual bleeding. Cycles may become shorter or longer, flow lighter or heavier, and periods may be skipped altogether. Other experiences, such as headaches, hot flashes, vaginal dryness, or sleep changes, may also happen (2,3).
What happens to periods during perimenopause?
During perimenopause, the ovaries produce less estrogen, and ovulation becomes unpredictable (5). During some cycles, an egg is released, and during others it’s not (5).
This is driven by hormonal changes, especially in estrogen levels (3). During the reproductive years, things follow a predictable pattern:
Ovarian follicles produce estrogen
A surge of luteinizing hormone (LH) triggers ovulation
After ovulation, the leftover follicle becomes a corpus luteum, which makes progesterone and some estrogen to prepare the body for a possible pregnancy.
If pregnancy does not happen, progesterone falls and your period starts (6).
During perimenopause, this pattern becomes unpredictable. Estrogen production declines, ovulation happens less often, and progesterone levels also fall (7). These changes can lead to less predictable cycles and are linked to many of the experiences people notice during perimenopause (like hot flashes or sleep changes) (7).
Different perimenopause experiences and symptoms explained
Perimenopause affects everyone differently. Some people notice almost no changes, others experience subtle shifts, and some feel more significant changes.
Common experiences may include:
Hot flashes and night sweats
Sleep changes, such as difficulty falling asleep or waking much earlier than usual
Changes in vaginal and urinary health, including vaginal dryness, pain during sex, increased vaginal infections, and urinary tract symptoms
Menstrual cycle changes, due to hormonal fluctuations affecting bleeding patterns (2,5).
Changes in bleeding patterns during perimenopause
Most people notice that periods start to feel a bit different during perimenopause. While this is common, it’s still important to tell your healthcare provider about any bleeding changes (2).
Abnormal uterine bleeding (AUB)
Sometimes, these changes can feel unpredictable or heavier than usual. Abnormal uterine bleeding describes bleeding from the uterus outside of pregnancy that’s unpredictable in timing, frequency, amount, or duration. It’s especially common during perimenopause, when hormonal changes often disrupt typical menstrual cycle patterns (8). In some cases, unusual bleeding can be a sign of other medical issues, so checking in can help you feel safe and supported (2,3).
Why bleeding changes happen
Hormonal changes, especially lower progesterone, can cause the uterine lining to thicken, leading to heavier periods (8,9). Cycle length and flow can also change: periods can be shorter or longer, lighter or heavier, and sometimes skipped altogether (5).
During early perimenopause, shorter cycles of less than 21 days are common
Later in the transition, longer cycles are more common
Spotting between periods and prolonged bleeding can also happen, especially as the final menstrual period approaches (10)
A well-known study measured how much blood women lose during their periods. It showed that women around age 50 lost about 6 mL more than women aged 20 to 45 (10). Heavy bleeding was most common for women getting close to their final menstrual period (10).
Why do periods sometimes get heavier?
Heavy bleeding is most often linked to cycles where ovulation happens, while very long bleeds or spotting are more often linked to cycles without ovulation (10).
Ovulation often becomes unpredictable and can be skipped altogether during perimenopause. Without ovulation, the corpus luteum doesn’t form, and progesterone remains low. This means the uterine lining continues to thicken under estrogen, eventually breaking down unevenly and causing unpredictable, prolonged, or heavy bleeding (11).
Other factors can contribute as well:
Fibroids can cause heavier periods and are most common in the perimenopausal years, and become less common after menopause (12). In one study, more than 30% of new fibroid diagnoses were in people aged 45-49 (12).
Endometrial polyps can disrupt bleeding patterns, often causing spotting between periods (13).
Weight changes can increase estrogen from fat tissue, which may thicken the uterine lining and lead to heavier or unpredictable bleeding (14).
How much bleeding is “normal” during perimenopause?
A typical menstrual cycle happens every 24–38 days, bleeding usually lasts 2–7 days, and results in 5–80 mL of blood loss (15). Changes in timing, duration, frequency, or amount may be a sign of abnormal uterine bleeding (15).
Bleeding more than 80 mL in a cycle is usually defined as heavy bleeding, but any bleeding that disrupts daily life also counts as heavy (11,15). People’s experiences vary—some feel their period is heavy even with less blood loss, while others with more blood loss may describe it as light (11).
Around 1 in 10 people experience heavy bleeding at some point, and the likelihood of seeking medical care increases with age, peaking between 45–49 years (11).
Some signs that you may be experiencing heavy bleeding are:
Needing to change menstrual products more than every 1–2 hours
Using more than 20 pads or tampons per cycle
Needing to change tampons or pads at night
Needing to use more than one pad at a time
Passing clots larger than the size of a quarter or a 10p coin
Bleeding for longer than 8 days
Developing iron deficiency anemia (11,15,16)
Iron-deficiency anemia is the most common type of anemia. It develops when the body doesn’t have enough iron to make healthy red blood cells (17). Symptoms can include fatigue, weakness, dizziness, headaches, pale skin, shortness of breath, rapid heartbeat, or brittle nails (17). If you think you might have iron-deficiency anemia, talk to your healthcare provider (17).
Managing heavy bleeding
There are different ways to manage heavy bleeding, from medical treatments to lifestyle changes. The right option depends on your body and your preferences.
Medical treatments
Treatments include both hormonal and non-hormonal options (13).
Hormonal IUD: This is the most effective treatment, reducing blood loss by up to 95% (13). It can improve quality of life as much as a hysterectomy (the surgical removal of the uterus) (13).
Combined birth control pill: This pill contains estrogen and progestin, and can reduce bleeding by up to 69%. It helps regulate cycles when ovulation is unpredictable (13). Continuous use may stop bleeding altogether, which some people prefer, but it’s not suitable for everyone during perimenopause, so talk to your healthcare provider (11,13).
Progestin-only pill: Continuous use of the progestin-only pill can reduce blood loss by up to 87%, though long-term satisfaction is often low (13).
The shot: This progestin-only injection is given every 13 weeks. Unpredictable bleeding is common at first, but about half of users have no bleeding after 1 year (13).
Non-hormonal options: Tranexamic acid or NSAIDs like naproxen can reduce bleeding by about 50% and are taken only during periods (13).
Surgical treatments
For some people, surgery may be needed to manage heavy bleeding:
Endometrial ablation or resection: This procedure destroys or removes the uterine lining, often reducing or stopping periods
Fibroids or polyps removal: These may also require surgical removal if they are the cause of heavy bleeding
A hysterectomy: Takes out the uterus completely, ending periods altogether. It’s the most effective option, but also the most invasive (18).
Lifestyle and daily management
Along with medical or surgical treatments, lifestyle changes can also help manage heavy bleeding.
Track your cycles: Tracking with Clue can make it easier to identify any patterns and share them with your healthcare provider (19)
Maintain a healthy weight: This may also help reduce bleeding. During perimenopause, obesity can raise the risk of abnormal uterine bleeding because excess fat tissue produces more estrogen, which can thicken the uterine lining and cause heavier periods (14)
Watch for anemia: As heavy bleeding can lead to iron-deficiency anemia, it is important to watch for the warning signs. If you notice fatigue, dizziness, shortness of breath, or a faster-than-usual heartbeat, talk to your healthcare provider (17)
Adapt your menstrual products: Different products hold different amounts—discs can hold up to 80 mL, while most cups, tampons, and heavy pads hold around 20–50 mL (20). Period underwear absorbs the least, about 2 mL, so it may be best used as a backup (20).
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When to see a healthcare provider
It’s common for your periods to change during perimenopause, but it’s still a good idea to check in with a healthcare provider. Changes in bleeding patterns can sometimes be a sign of underlying medical conditions (5). If you notice any vaginal bleeding after menopause, this is not typical, so it’s important to tell your healthcare provider (5).
If you think you may have iron-deficiency anemia, talk to your healthcare provider. Anemia often develops slowly and may start with no or mild symptoms (17).
You should seek medical help right away if you experience sudden heavy bleeding and need to change pads or tampons every hour for more than 2 hours, and you have chest pain, shortness of breath, lightheadedness, or dizziness (21).
Tracking with Clue Perimenopause mode
With Clue’s Perimenopause mode, you can track experiences like bleeding, hot flashes, night sweats, and vaginal dryness. Noticing patterns over time can help you feel more in tune with your body. It can also help you feel supported as you move through this phase of life and provide you with useful information to share with your healthcare provider.
FAQs
Is it “normal” to bleed heavily during perimenopause?
Heavier periods are common in perimenopause because ovulation becomes unpredictable, and hormonal changes can keep the uterine lining growing. Fibroids or polyps also become more frequent in perimenopause, and these can cause heavy bleeding. Just because it’s common does not mean you should ignore it. It’s important to see a healthcare provider if your bleeding pattern changes or you experience symptoms of anemia (5,9,12).
What is perimenopausal flooding?
Acute heavy menstrual bleeding, sometimes referred to as “flooding,” is a sudden, very heavy gush of bleeding. If it lasts more than 2 hours or if you feel lightheaded, short of breath, or have chest pain, it’s a medical emergency and you should seek immediate care (21,22).
How can I stop heavy bleeding during perimenopause naturally?
Avoid taking aspirin if you experience heavy bleeding because aspirin can make bleeding heavier by affecting blood clotting (16). A study showed that adding ginger or frankincense to Ibuprofen reduced bleeding duration, and a smaller trial showed that ginger reduced blood loss, but it’s not clear whether these effects apply in perimenopause (23,24).
For people with fibroids, taking epigallocatechin gallate (EGCG), a green tea compound, with vitamin D and B6 may help reduce fibroid size and ease heavy bleeding (25,26).
