Much is said about Menopause, but less about Perimenopause and the related perimenopausal bleeding or spotting. Women have lots of questions about Perimenopause, particularly regarding the menstrual cycle, bleeding or spotting during this stage.
What is Perimenopause?
Perimenopause is the transition into menopause when a woman’s body begins to slow the production of hormones. Women most often experience perimenopause signs and symptoms in their early 40s, but for some it can begin in their 30s. This transition time can last anywhere from 4-7 years. Read more about Perimenopause
What are the symptoms of Perimenopause?
The symptoms of Perimenopause are occasional hot flashes, sleep problems, vaginal dryness, mood changes, inability to concentrate, free floating anxiety and Irregular periods.
Why is there irregular periods or spotting during perimenopause?
Dr Steven R. Goldstein, a Menopause Specialist in NYC and co author of the book “Could it be… Perimenopause?”outlines the following about Perimenopausal bleeding or spotting. Think of perimenopause as the mirror image of adolescence. Adolescence is the coming on to the reproductive years while perimenopause is the coming off of the reproductive years.
In both of these timeframes, regular ovulatory cycles are less likely. To patients, all the blood that comes out of their vagina is their “period,” whereas to me as a clinician, a “menses” is a bleed preceded two weeks before by ovulation. If one does not ovulate but is making estrogen, when and how much one bleeds is related to the stability of the estrogen levels without progesterone. When there is fluctuation, it destabilizes the uterine lining, and it can be shed, causing bleeding.
The hallmark of cycles with ovulation is their predictability, regularity, and cyclicity. The hallmark of cycles without ovulation is being potentially “all over the map.” They can be heavy, they can be light, they can be continuous or intermittent. As they are in perimenopause. The hallmark is the inconsistency, whereas pre-menopausal ovulatory cycles are characterized by predictability, consistency, and regularity.
In a large study conducted by us more than twenty years ago, 79% of women over the age of thirty-five who had any irregularity to their bleeding cycle had no anatomic reason such as polyps, fibroids, pre-cancers, and even occasional cancers. Thus, these 79% had irregular bleeding or spotting due to “hormone imbalance,” what doctors tell patients when they are not ovulating and thus not making progesterone on a regular basis.
What can be done about irregular or abnormal bleeding or spotting?
The guidelines state that any women over forty who is having any irregular, abnormal bleeding or staining or spotting needs to have her uterine lining (endometrium) evaluated to rule out structural, anatomic reasons for the bleeding.
Whereas, years ago the primary diagnostic procedure was a D&C (dilitation and curettage also known as “scraping”) today we use transvaginal ultrasound and, when necessary, saline infusion into the uterine cavity to better delineate the presence or absence of any anatomic abnormality. If the bleeding is “hormone imbalance,” then such patients can be reassured and almost always treated hormonally.
If the bleeding is from some structural abnormality (polyps, fibroids, pre-cancers, or even potential cancers) then either endometrial biopsy if the process involves the entire uterine cavity, or D&C hysteroscopic visualization under anesthesia, if the process involves only a portion of the uterine cavity mainly because in those instances, a blind biopsy may miss the area of interest.
Dr Steven R. Goldstein is a past President of the International Menopause Society, past President of the North American Menopause Society, a Certified Menopause Practitioner and one of the nation’s top doctors in gynecology. He is also the co-author of the book “Could it be….Perimenopause?” If you think you are experiencing perimenopause or have irregular bleeding, you may schedule a consultation with Dr Goldstein at this link.
You can read more about Dr Goldstein at this page
This post was last modified on February 28, 2024 8:00 pm