Perimenopausal bleeding: Changes before the change

Although some women may abruptly stop having periods leading up to the menopause, many will notice changes in patterns and irregular bleeding. Whilst this can be a natural phase in your life, it may be important to see your healthcare professional to rule out other health conditions if other worrying symptoms occur.

What is menopause?

Menopause is a transition which marks the end of your reproductive years. As your ovaries run out of eggs, your body is no longer required to produce as much oestrogen, and so oestrogen levels in the blood will drop. This drop in oestrogen will lead to a number of menopausal changes for your body.

What is perimenopause?

"Peri" is a prefix which means around, or about. So, just as a perimeter may be around a garden, perimenopause is the time around menopause. On average, perimenopause will last four years.

What are the symptoms?

The changes in hormone levels can lead to a varied set of physical and emotional symptoms. As with menstruation in younger life, all women will experience perimenopause differently. While they are all common in perimenopause, women will experience different combinations of the symptoms below, and to varying degrees:

Headaches

Aches and pains in joints and muscles

Breast tenderness

Hot flushes

Night sweats

Racing heartbeat or palpitations

Reduced bladder control

Vaginal dryness or pain during sexual intercourse

An increased risk of vaginal and urinary infections

Reduced sex drive

Fatigue or low energy levels

Difficulty concentrating

Lapses in memory

Depression

Mood swings and irritability

Changes to skin, hair and nails

Weight gain, particularly to the waist and abdomen.

On top of these symptoms, women in perimenopause may experience a more irregular menstrual cycle.  Some women find their cycles become shorter, meaning periods come only two or three weeks apart. Other women may not have a period for months at a time. The flow can also be affected, with periods being heavier or lighter than normal. Whichever way these changes occur, menopause will eventually cause your periods to stop altogether.

Typically, women experience menopause between the ages of 47 and 53, with the average menopausal age being 51 years. Although the symptoms listed above are common during perimenopause, it is still advisable to visit a healthcare professional to discuss the changes as it is possible that your symptoms could be pointing towards more serious health conditions.

Should I visit my GP?

Many women experience Abnormal Uterine Bleeding (AUB) during perimenopause. AUB is defined as bleeding that differs in frequency, regularity, duration or amount to your regular menstrual bleeding. Changes to the menstrual cycle often carry no significant consequences; however, they could have a range of causes. So, although it may simply be a symptom of perimenopause, it is still sensible to raise the issue with your healthcare professional. In most cases, a thorough history and physical examination will indicate the cause of AUB and help discern the need for further investigation and treatment.

What else may cause AUB?

One potential cause of AUB is cancer, which begins when abnormal cells divide and multiply in an uncontrolled way. There are over 200 types of cancer. Some uncommon types are caused by faulty genes which are passed down through families; others start due to gene changes over time.

Typically, cancer of the uterus begins with the cells which make up the lining of the womb, also known as the endometrium. Because of this, cancer of the uterus is often referred to as endometrial cancer.

Menopause itself is not linked to an increased risk of cancer. In fact, the development of endometrial cancer is predominantly related to excess oestrogen exposure, whilst menopause causes a decrease in oestrogen production. However, factors such as age or a late menopause are risk factors for endometrial cancers. This is why symptoms such as AUB should not be ignored.

How do I know it's AUB?

In perimenopausal women, AUB can be defined as ovulatory or anovulatory, dependent on whether you are still ovulating. Ovulatory bleeding, where you are still producing eggs, is linked to the menstrual cycle, ovulation and is associated with typical premenstrual symptoms and painful periods. Anovulatory bleeding, which is found more frequently in perimenopause than premenopause, is often linked to prolonged periods and a heavier flow. It is this anovulatory bleeding which has a stronger link to endometrial hyperplasia (when the lining of the uterus becomes too thick) and cancer.

Perimenopausal and postmenopausal bleeding, AUB with a history or anovulation, and sonograph results which indicate a thickened endometrium, are all scenarios where a biopsy of the endometrium may be advised. Other symptoms of endometrial cancers include pain to the back and pelvic areas, and pain during intercourse and discomfort when urinating.

You may have noticed that these symptoms are all closely related to those which are associated with perimenopause. It is understandable why women may brush their concerns to one side and blame it on "the time of life". However, understanding your own cycles and knowing what is normal for you will help you recognise when something is not quite right.

When considering your own cycle, there are a few red flags which mean it is time to visit your GP:

Bleeding that requires a new pad every hour for over 24 hours

Bleeding that lasts over two weeks

Any bleeding once periods have been absent for over six months.

If you are concerned about AUB, it can help to keep a record of your symptoms and take these with you when raising the issue with your healthcare professional. This may help with their examination and diagnosis.

Any AUB experienced after the menopause is unusual and it is important that you raise this with your healthcare professional. Women who start oestrogen replacement therapy may be an exception to this.

What else may affect the risks of endometrial cancer?

There are a number of risk factors which are linked to endometrial cancer. These factors could potentially increase or decrease your risk:

There is evidence to suggest that having children later in life can reduce the risk of developing endometrial cancer. Research has shown that women who give birth at 40 years or older, have 44% lower risk when compared to women who had their last child at age 25 years.

As with a number of medical conditions, the risk of endometrial cancer is strongly associated with obesity, particularly women with a Body Mass Index (BMI) over 30kg/m.  Addressing your BMI may potentially reduce the risk of developing endometrial cancer, as well as having other positive health benefits. Being significantly overweight can also have an impact on treatment options for endometrial cancer. For overweight women, invasive surgery may not be a good option as complications can occur during treatment or during the recovery period.

It's possible that regular physical activity can have a protective effect against endometrial cancer, but more studies are needed to more accurately estimate the magnitude or effect.

Can I relieve the symptoms of AUB?

Living with AUB can be troubling, and it's important to address the root cause before dismissing it as a symptom of perimenopause. But that's not to say you can't try to alleviate the symptoms of AUB and make the condition easier to live with.

Although few women complain about a decrease in menstrual bleeding, living with excessive bleeding can have detrimental effects on a woman's quality of life. Not only can AUB cause stress and discomfort, with heavy and unpredictable bleeding, but it can even have an economic impact by causing missed work days.

These are our top 5 tips for relieving some common symptoms of AUB, and they may help combat other perimenopausal symptoms too:

Increase your iron intake

If your AUB is causing you to have a heavier or more frequent period, the increased blood loss can lead to anaemia as your body struggles to replenish iron. Increasing your iron intake can help to reduce the risk of becoming anaemic. Iron rich foods include spinach and other leafy greens, red meat and eggs. You may also find certain breads or cereals have added iron.

Hormone therapy

Using oral contraceptives or progestogens, can help decrease heavy bleeding and regulate the menstrual cycle. Hormone therapy can also be used to suppress the growth of endometrial tissues. Your doctor will be able to advise whether hormone therapy is suitable for you, individualisation is key in the decision to use this kind   of treatment. Personal risk factors, such as age, time since menopause, risk of heart disease, stroke or breast cancer, should all be taken into consideration.

Herbal remedies

Using herbal remedies, such as a black cohosh, can help treat uterine disorders by promoting and restoring healthy menstrual activity. Black cohosh may also relieve other perimenopausal symptoms, such as hot flushes, vaginal dryness and disturbed sleep.

Black cohosh belongs to the buttercup family and is available as capsules, tablets, powdered or as a liquid. Although there is little scientific evidence behind the treatment, black cohosh was used by Native Americans for centuries to medicate menstrual cramps and menopausal symptoms, among other ailments.

Anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed for the first three days of menstruation to reduce blood flow. In AUB which is a result of endometrial dysfunctions or ovulatory dysfunctions, NSAIDs has been shown to reduce menstrual bleeding. This sort of treatment should be discussed with your healthcare professional.

Intrauterine Device (IUD)

IUDs are an effective form of contraception; however, they can also relieve the symptoms of AUB by suppressing the growth of the endometrium and significantly reducing menstrual blood loss. There are a number of IUDs available as contraceptive devices, but the levonorgestrel-releasing intrauterine system (LNG- IUS) has been linked with a significant 95% reduction in menstrual blood loss.

What next?

If you have any concerns about perimenopause, or any of the conditions discussed in this leaflet, please visit your healthcare professional. They will be able to help you explore options for diagnosis, prevention and symptom management, as well as treatment options where needed.

Perimenopausal bleeding: Changes before the change

Although some women may abruptly stop having periods leading up to the menopause, many will notice changes in patterns and irregular bleeding. Whilst this can be a natural phase in your life, it may be important to see your healthcare professional to rule out other health conditions if other worrying symptoms occur. What is menopause? Menopause is a transition which marks the end of your reproductive years. As your ovaries run out of eggs, your body is no longer required to produce as much oestrogen, and so oestrogen levels in the blood will drop. This drop in oestrogen will lead to a number of menopausal changes for your body. What is perimenopause? Peri is a prefix which means around, or about. So, just as a perimeter may be around a garden, perimenopause is the time around menopause. On average, perimenopause will last four years. What are the symptoms? The changes in hormone levels can lead to a varied set of physical and emotional symptoms. As with menstruation in younger life, all women will experience perimenopause differently. While they are all common in perimenopause, women will experience different combinations of the symptoms below, and to varying degrees: Headaches Aches and pains in joints and muscles Breast tenderness Hot flushes Night sweats Racing heartbeat or palpitations Reduced bladder control Vaginal dryness or pain during sexual intercourse An increased risk of vaginal and urinary infections Reduced sex drive Fatigue or low energy levels Difficulty concentrating Lapses in memory Depression Mood swings and irritability Changes to skin, hair and nails Weight gain, particularly to the waist and abdomen. On top of these symptoms, women in perimenopause may experience a more irregular menstrual cycle. Some women find their cycles become shorter, meaning periods come only two or three weeks apart. Other women may not have a period for months at a time. The flow can also be affected, with periods being heavier or lighter than normal. Whichever way these changes occur, menopause will eventually cause your periods to stop altogether. Typically, women experience menopause between the ages of 47 and 53, with the average menopausal age being 51 years. Although the symptoms listed above are common during perimenopause, it is still advisable to visit a healthcare professional to discuss the changes as it is possible that your symptoms could be pointing towards more serious health conditions. Should I visit my GP? Many women experience Abnormal Uterine Bleeding (AUB) during perimenopause. AUB is defined as bleeding that differs in frequency, regularity, duration or amount to your regular menstrual bleeding. Changes to the menstrual cycle often carry no significant consequences; however, they could have a range of causes. So, although it may simply be a symptom of perimenopause, it is still sensible to raise the issue with your healthcare professional. In most cases, a thorough history and physical examination will indicate the cause of AUB and help discern the need for further investigation and treatment. What else may cause AUB? One potential cause of AUB is cancer, which begins when abnormal cells divide and multiply in an uncontrolled way. There are over 200 types of cancer. Some uncommon types are caused by faulty genes which are passed down through families; others start due to gene changes over time. Typically, cancer of the uterus begins with the cells which make up the lining of the womb, also known as the endometrium. Because of this, cancer of the uterus is often referred to as endometrial cancer. Menopause itself is not linked to an increased risk of cancer. In fact, the development of endometrial cancer is predominantly related to excess oestrogen exposure, whilst menopause causes a decrease in oestrogen production. However, factors such as age or a late menopause are risk factors for endometrial cancers. This is why symptoms such as AUB should not be ignored. How do I know its AUB? In perimenopausal women, AUB can be defined as ovulatory or anovulatory, dependent on whether you are still ovulating. Ovulatory bleeding, where you are still producing eggs, is linked to the menstrual cycle, ovulation and is associated with typical premenstrual symptoms and painful periods. Anovulatory bleeding, which is found more frequently in perimenopause than premenopause, is often linked to prolonged periods and a heavier flow. It is this anovulatory bleeding which has a stronger link to endometrial hyperplasia (when the lining of the uterus becomes too thick) and cancer. Perimenopausal and postmenopausal bleeding, AUB with a history or anovulation, and sonograph results which indicate a thickened endometrium, are all scenarios where a biopsy of the endometrium may be advised. Other symptoms of endometrial cancers include pain to the back and pelvic areas, and pain during intercourse and discomfort when urinating. You may have noticed that these symptoms are all closely related to those which are associated with perimenopause. It is understandable why women may brush their concerns to one side and blame it on the time of life. However, understanding your own cycles and knowing what is normal for you will help you recognise when something is not quite right. When considering your own cycle, there are a few red flags which mean it is time to visit your GP: Bleeding that requires a new pad every hour for over 24 hours Bleeding that lasts over two weeks Any bleeding once periods have been absent for over six months. If you are concerned about AUB, it can help to keep a record of your symptoms and take these with you when raising the issue with your healthcare professional. This may help with their examination and diagnosis. Any AUB experienced after the menopause is unusual and it is important that you raise this with your healthcare professional. Women who start oestrogen replacement therapy may be an exception to this. What else may affect the risks of endometrial cancer? There are a number of risk factors which are linked to endometrial cancer. These factors could potentially increase or decrease your risk: There is evidence to suggest that having children later in life can reduce the risk of developing endometrial cancer. Research has shown that women who give birth at 40 years or older, have 44% lower risk when compared to women who had their last child at age 25 years. As with a number of medical conditions, the risk of endometrial cancer is strongly associated with obesity, particularly women with a Body Mass Index (BMI) over 30kg/m. Addressing your BMI may potentially reduce the risk of developing endometrial cancer, as well as having other positive health benefits. Being significantly overweight can also have an impact on treatment options for endometrial cancer. For overweight women, invasive surgery may not be a good option as complications can occur during treatment or during the recovery period. Its possible that regular physical activity can have a protective effect against endometrial cancer, but more studies are needed to more accurately estimate the magnitude or effect. Can I relieve the symptoms of AUB? Living with AUB can be troubling, and its important to address the root cause before dismissing it as a symptom of perimenopause. But thats not to say you cant try to alleviate the symptoms of AUB and make the condition easier to live with. Although few women complain about a decrease in menstrual bleeding, living with excessive bleeding can have detrimental effects on a womans quality of life. Not only can AUB cause stress and discomfort, with heavy and unpredictable bleeding, but it can even have an economic impact by causing missed work days. These are our top 5 tips for relieving some common symptoms of AUB, and they may help combat other perimenopausal symptoms too: Increase your iron intake If your AUB is causing you to have a heavier or more frequent period, the increased blood loss can lead to anaemia as your body struggles to replenish iron. Increasing your iron intake can help to reduce the risk of becoming anaemic. Iron rich foods include spinach and other leafy greens, red meat and eggs. You may also find certain breads or cereals have added iron. Hormone therapy Using oral contraceptives or progestogens, can help decrease heavy bleeding and regulate the menstrual cycle. Hormone therapy can also be used to suppress the growth of endometrial tissues. Your doctor will be able to advise whether hormone therapy is suitable for you, individualisation is key in the decision to use this kind of treatment. Personal risk factors, such as age, time since menopause, risk of heart disease, stroke or breast cancer, should all be taken into consideration. Herbal remedies Using herbal remedies, such as a black cohosh, can help treat uterine disorders by promoting and restoring healthy menstrual activity. Black cohosh may also relieve other perimenopausal symptoms, such as hot flushes, vaginal dryness and disturbed sleep. Black cohosh belongs to the buttercup family and is available as capsules, tablets, powdered or as a liquid. Although there is little scientific evidence behind the treatment, black cohosh was used by Native Americans for centuries to medicate menstrual cramps and menopausal symptoms, among other ailments. Anti-inflammatory drugs Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed for the first three days of menstruation to reduce blood flow. In AUB which is a result of endometrial dysfunctions or ovulatory dysfunctions, NSAIDs has been shown to reduce menstrual bleeding. This sort of treatment should be discussed with your healthcare professional. Intrauterine Device (IUD) IUDs are an effective form of contraception; however, they can also relieve the symptoms of AUB by suppressing the growth of the endometrium and significantly reducing menstrual blood loss. There are a number of IUDs available as contraceptive devices, but the levonorgestrel-releasing intrauterine system (LNG- IUS) has been linked with a significant 95% reduction in menstrual blood loss. What next? If you have any concerns about perimenopause, or any of the conditions discussed in this leaflet, please visit your healthcare professional. They will be able to help you explore options for diagnosis, prevention and symptom management, as well as treatment options where needed.