What constitutes normal menstrual bleeding after 40?
When health experts talk about normal menstrual bleeding, it's usually about younger women. So what is normal when a woman approaches perimenopause?
“Welcome to perimenopause!”
This is what a doctor specializing in women’s hormone health said after I told her about a long-lasting period and spotting. She went on to say how wacky my periods will get.
“Sometimes you’ll bleed a lot other times not at all,” she said. After my pelvic exam she said everything looked good. She even complemented my vagina!
Then she told me to return in 6 months and she’d take a bunch of tests. Three-hundred dollars poorer (I paid out of pocket) and no better off than I was before, I never went back.
But my cycles did go back to normal for several months but then the process repeated itself.
So what is abnormal bleeding after 40?
The American College of Obstetricians of Gynecologists (ACOG) define abnormal uterine bleeding (AUB) as:
“Bleeding from the uterine corpus that is abnormal in its regularity, volume, frequency or duration and is not associated with pregnancy.”
In premenopausal women bleeding issues are either due to structural such like polyps or fibroids or nonstructural causes like ovulatory disorders. But they only discuss pre and post menopause and not perimenopausal women.
Another bleeding issue that’s common is heavy menstrual bleeding defined by blood loss during a cycle of >80ml of blood.
Each soaked, normal sized sanitary products holds about 5 ml of blood. So, if a woman soaks 16 or more, that’s considered heavy menstrual bleeding.
Isn’t the definition of perimenopause the same as AUB?
From where I stand, the definition of AUB is basically what happens during perimenopause. Unfortunately, perimenopausal women are kind of left out of this conversation.
In one study with 1320 midlife women, three out of four experienced at least three episodes of 10+ days of bleeding. Periods followed by spotting occurred in over half of them. And periods with heavy bleeding for three or more days occurred in one out of three with 40% experiencing heavy bleeding three times in 6 months.
Perimenopause is officially defined as a change in cycles by 7 days. Most have short (<21 day) or long (>36 days) cycles that are increasingly anovulatory which means there’s no progesterone activity.
To give you an idea, one study showed that in early perimenopause 20% of the cycles where anovulatory and this jumped to 60% in late perimenopause.
Anovulatory cycles are more likely to produce spotting and sporadic, heavy bleeding. After all, estrogen thickens the lining while progesterone thins it. The drop in both hormones is what causes menstruation when cycles are normal.
But with no progesterone during some perimenopause cycles, this all gets messed up.
My new doctor reacted differently
With my bleeding picking up - mixture of short cycles and long periods - I made an appointment with a North American Menopause Society (NAMS) practitioner.
Right away the NAMS doctor acted, ordering an ultrasound and biopsy. She wanted to rule out any issues and check the health of my uterus.
The ultrasound revealed a polyp and the plan is to have it removed in a procedure called hysteroscopy along with a D&C to evaluate the endometrial lining.
Polyps are typically benign growths on the uterine wall and are quite common.
Is the bleeding due to polyps or hormones?
I have yet to have the procedure and still have many questions. Polyps are linked to AUB and heavier bleeding. But isn't it likely the bleeding is a combination of hormonal changes and the polyp is making it worse?
The big C is always something women need to be aware about. The average age of diagnosis for endometrial cancer is 60. And risk is much higher post menopause.
It can happen at younger ages (rare under 45) so getting checked out is always smart.
What women need to know about periods after 40
Very early perimenopause (cycles still regular): Be on the lookout for heavier periods. Although taking ibuprofen as directed on heavy days can decrease flow, you may want to see a gynecologist for options. Ask your doctor about progesterone or the Mirena IUD.
Consider getting an AMH test to predict when you will go through menopause. If it’s more than 5 year, it may change your decision. Get your ferritin checked because most will be iron deficient.
Perimenopause (change in cycles by 7 days): Same as above; find a NAMS practitioner and ask about progesterone to balance your cycles. Periods lasting longer than 10 days and lots of spotting warrants an evaluation.
Menopause/post menopause: Defined as 12 months without a period, any bleeding needs prompt attention from a doctor.
For more on the menstrual cycle, health, and progesterone, listen to my conversation with Dr. Jerilynn Prior.
How did things turn out?
My surgery was fine and there was no signs of hyperplasia (pre cancerous tissue). Eventually my bleeding decreased and periods got further apart. Once you go more than 60 days without a cycle you are in late perimenopause. That’s where I am now.
And I’m not going to lie, it’s pretty nice.
How has your menstrual bleeding been during midlife?