Vaginal bleeding during perimenopause and menopause Factsheet

The main advantage of the menopause is that you don’t have to put up with periods anymore. So, you may be surprised – and disheartened ­ to notice that you still bleed from time to time.

Vaginal bleeding can occur in some women after their periods have finished and also in women who take HRT. For the vast majority of women, it does not need to be a cause for concern. This factsheet outlines reasons why you might bleed and when you should seek advice from a healthcare professional.

Why does it happen?

The frequency, duration and amount of bleeding varies tremendously between women, especially during the perimenopause. In between periods, or after you thought they were long gone, you might notice some occasional spotting or brown discharge. For some, it could be as heavy as a period and last for days or even weeks.

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 the uterus but for most women, vaginal bleeding is due to hormonal changes. During the perimenopause, your estrogen levels can have greater fluctuations throughout the month and when there are high levels of estrogen, bleeding can sometimes occur.

Bleeding on HRT

For those of you taking HRT, you may be using a type of HRT that 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 so are not due to have any bleeding, but find that you still do on occasions.

Either way, bleeding on HRT can be common, especially for the first three months after starting it, or changing the dose or type of HRT. It is important to mention any bleeding you are experiencing to your healthcare professional when you go for your review appointment about your HRT, or make an earlier appointment if your bleeding is heavy or persistent.

It is likely your healthcare professional 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 reason for the bleeding. The healthcare professional may also recommend other investigations.

Is there any treatment and when should I seek help?

Treatments for vaginal bleeding very much depend on what the cause is. If you are taking HRT and bleeding is still happening after 3­-6 months, it is usually worth considering changing the type or dose of HRT, or the way it is taken, for example, from a tablet or patch to a gel or spray (for your estrogen replacement) or to consider a Mirena coil (for the progestogen component). The aim of this is to try and get the right balance of estrogen and progestogen for you individually, and this can sometimes take a few months to figure out. 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 the 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 had the menopause 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

1. 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.
   
2. 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 ­ get it checked out by a healthcare professional.
   
3. Look at your HRT
   It is extremely common to bleed during the first three months of taking HRT, if it hasn’t settled after this time, many women find that altering the dose or type of estrogen and progestogen – or the way it is taken – usually helps minimise any bleeding.
   
4. Wear period pants
   Period pants – these are not just the worst knickers in your drawer – are great for coping with unexpected bleeding. They are leakproof underwear made from fabric that absorbs and wicks away liquid to keep you dry and comfortable throughout the day. They can usually cope with around 2 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 are also useful if you suffer with occasional leaks of urine and are great for giving peace of mind when you’re out and about.