Heavy or prolonged periods
Flooding, clots, frequent product changes or bleeding that disrupts sleep or daily life are worth treating. Tiredness, breathlessness and dizziness can suggest anaemia.
PATIENT GUIDE
Bleeding during perimenopause
Changing periods are common during the menopause transition. Heavy, persistent or unexpected bleeding still needs a clear explanation and a treatment plan that fits your life.
UNDERSTANDING YOUR BLEEDING
Changing cycles still deserve attention.
During perimenopause, ovulation becomes less predictable and periods can become closer together, farther apart, lighter or heavier. Fibroids, polyps, adenomyosis, pregnancy, medication and changes in the uterine lining can also cause bleeding. A hormone explanation should not end the assessment.
Bleeding between periods or after sex
New or recurring spotting needs assessment of its source. The cervix, vagina and uterine lining may each need consideration. A normal cervical screening result does not replace a symptom assessment.
Periods that stop and restart
Twelve months without natural periods usually marks menopause at the usual age. Unexplained bleeding afterwards needs the postmenopausal bleeding guide →. Hormonal contraception and HRT can alter this interpretation.
ASSESSMENT
What will the assessment involve?
Your pattern and priorities
Record dates, duration, flooding, pain and any bleeding between periods or after sex. Bring medicines and contraception details, including missed doses and the date a hormonal IUS was inserted.
Choose useful tests
A pregnancy test may be needed. A blood count checks for anaemia with heavy bleeding; iron or thyroid tests are added when indicated. Routine hormone panels rarely explain abnormal bleeding in women over 45.
Examination and ultrasound
We discuss an examination, including the cervix when relevant, and whether ultrasound will help identify a structural cause. You can ask questions, request a pause or stop. There is no single reliable “normal lining thickness” cut-off for everyone who is still cycling.
Sampling when indicated
Age, persistence, bleeding pattern, risk factors and scan findings determine whether endometrial sampling or hysteroscopy is needed. This is particularly relevant from 45, or earlier with risk factors. Hysteroscopy can identify and sample a focal lesion such as a polyp. A reassuring scan does not end the evaluation of persistent unexplained bleeding.
TREATMENT CHOICES
Match treatment to the cause and your goals.
Reduce heavy bleeding
Options may include tranexamic acid, suitable anti-inflammatory medicines, a hormonal IUS or other hormonal treatment. Medical history, clot risk, contraception and pregnancy plans affect the choice. Anaemia or iron deficiency may need treatment too.
Treat a structural cause
A polyp or suitable fibroid may be treated hysteroscopically. Ablation or hysterectomy is considered only after discussing alternatives, suitability, fertility and contraception. Ablation does not prevent pregnancy.
Manage menopause symptoms
HRT may help flushes and sweats but is not contraception and is not a substitute for investigating abnormal bleeding. We can plan bleeding control and symptom care together. See HRT choices → and bleeding while using HRT →.
PREGNANCY PREVENTION
Stopping contraception needs a separate plan.
Periods becoming irregular does not mean pregnancy is impossible. When using a non-hormonal method, guidance generally advises contraception for two years after the last natural period if under 50, and one year if 50 or older. Hormonal methods can hide the natural pattern, so different rules apply; contraception can usually stop at 55. Read the perimenopause contraception explanation → and check your own method before stopping.
If you use a 52 mg hormonal IUS with oestrogen, its role in protecting the uterine lining has a specific replacement interval. A contraceptive extension does not automatically extend HRT protection.
Back to contents ↑A PLAN TO REVIEW
If bleeding has not improved.
Track the change after treatment, side effects and any missed tablets or doses. Ask when improvement should occur and when to return. Persistent bleeding, recurrent anaemia or new symptoms may require another assessment even if an earlier test was reassuring. Confirm who will communicate biopsy or scan results.
WHEN TO SEEK HELP
When bleeding needs urgent help.
Emergency care: very heavy bleeding with faintness, collapse, severe pain, chest pain or breathlessness. Possible pregnancy with one-sided pain or shoulder-tip pain also needs emergency assessment.
Seek same-day advice for rapidly increasing or prolonged heavy bleeding, fever with pelvic pain, or feeling unwell. Arrange prompt assessment for bleeding after menopause. Do not wait for a routine appointment response if symptoms are severe.
COMMON QUESTIONS
Questions you may still have.
Is irregular bleeding always normal in perimenopause?
No. Cycle changes are common, but heaviness, persistence, bleeding between periods or after sex, and your health history affect what needs checking.
Will I definitely need a biopsy?
No. The decision follows your age, symptoms and risk, alongside examination and imaging where useful. If recommended, we explain the procedure, pain relief and alternatives.
Can one treatment help bleeding and contraception?
Sometimes. A suitable hormonal IUS or contraceptive can help both. Treatment for flushes and sweats may still need a separate discussion.
YOUR NEXT STEP
A plan that fits your circumstances.
Bring previous results, the names or photographs of your medicines and your main questions. You do not need to arrange tests before booking.
General information to support your consultation. Your assessment and prescription are individual.
Page updated: .
Sources & further reading: NICE: heavy menstrual bleeding → · HSE: contraception and menopause →