Perimenstrual Signs: What’s Normal and What’s Not

How to spot the first signs of perimenopause—and when to consult a doctor

by The North American Menopause Society
woman concerned image

One of the first signs of perimenopause is a change in menstrual periods or uterine bleeding. These changes often are caused by lack of ovulation (anovulation) or infrequent ovulation (oligoovulation), normal and natural occurrences in perimenopause. Often, no evaluation or treatment is needed. However, there are times when uterine bleeding patterns require consultation with your healthcare provider to evaluate the cause and determine if treatment is required.

See a healthcare provider if you experience any of the following:

  • Heavy bleeding, often with clots, especially if periods haven’t been that way in the past 
  • Periods lasting over 7 days, or more than 2 to 3 days longer than usual 
  • Frequent periods, with intervals shorter than 21 days from the start of one period to the start of the next 
  • Spotting or bleeding between periods 
  • Bleeding from the vagina after sexual intercourse

There are many possible causes of abnormal uterine bleeding. These include:

  • Benign or noncancerous conditions of the reproductive tract:
  • Pregnancy
  • Irregular or absent ovulation
  • Hormonal imbalance 
  • Fibroids
  • Polyps of the cervix or uterine lining
  • Infections or abnormalities in the pelvis, uterus, cervix, or vagina


  • Hormonal contraceptives
  • Blood thinners
  • Tamoxifen
  • Corticosteroids
  • Certain herbal products 

Diseases or systemic causes:

  • Blood-clotting disorders such as von Willebrand’s disease and leukemia
  • Thyroid dysfunction
  • Liver disease
  • Obesity
  • Anorexia
  • Rapid fluctuations in weight
  • Chronic illness 

Cancer or precancerous changes:

  • Abnormal overgrowth of the uterine lining
  • Cancer of the cervix or uterine lining

Initial evaluation by a healthcare provider includes a pelvic examination and blood tests. A pelvic ultrasound, tissue sampling of the uterine lining (endometrial biopsy), or possibly a minor surgical procedure where the uterus is examined through a fiberoptic instrument (hysteroscopy) is often the next step. Once the cause of the bleeding is determined, the appropriate medical or surgical therapy will be selected.

The most common cause of abnormal uterine bleeding in perimenopausal women is irregular ovulation. There are a number of effective hormonal treatment options, including oral contraceptives, intermittent or continuous progestogen therapy, or even an IUD containing a small amount of progestogen. Taking iron can prevent the anemia that sometimes accompanies prolonged or excessive bleeding (but take iron only on the advice of your healthcare provider).

Many women find that tracking their periods on a menstrual calendar is an easy and useful way of identifying their own bleeding patterns. It will help them determine what their usual pattern is, when patterns change, if a consultation with their healthcare provider is recommended, and the effectiveness of treatment, should it be necessary.

Next: Are You Experiencing Early Menopause?

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