Please characterize the bleeding pattern of women during the transition to menopause. #606/15

Q:        Can you explain the changes in bleeding patterns in women before and during menopause?

A:        The menopausal transition:  Counsel on changes in bleeding patterns:

“Results of a new national study indicate it is not uncommon for women to have prolonged bleeding of 10 or more days, spotting for six or more days, and/or heavy bleeding for three or more day during the transition to menopause.  Of the more than 1.300 women ages 42-52 in the study, 91% recorded one to three occurrences in a three-year period of bleeding that lasted 10 or more days, nearly 88% reported six or more days of spotting, and close to 78% recorded three or more days of heavy flow.”

“Data for the Study of Women’s Health Across the Nation (SWAN) involved participants recording their experineces over a period of time during the years 1996 to 2006.  The women were identified as African-American, Japanese, Chinese, and white, and they were from southeast Michigan, Los Angeles, and northern California.” 

“For most women, menstrual cycles in the reproductive years before the menopausal transition starts are very predictable, observes Sioban Harlow, PhD, professor of epidediology at the University of Michigan in Ann Arbor.” 

“With the onset of the menopausal transition, menstrual cycles change, often dramatically.  Knowledge of what to expect provides an important frame of reference and can help clinicians better understand and evaluate the bleeding changes women experience during the menopausal transition.”

What does Dr. Sioban Harlow suggest that clinicians look for?

“ The paper provides clinicians with quantitative data that describe the likelihood women will experience long and heavy bleeding during the menopausal transiition, notes John Randolph, Jr., MD, professor of obstetrics and gynecology at the University of Michigan.  Most women will experience one or more periods that are longer than what they are accustomed to, but these long periods are often self-limiting, notes Randolph, a paper co-author.  Periods of 10 days are not uncommon, unlike what most women experience during their reproductive years, says Randolph.  Such long and/or heavy bleeding would prompt clinical investigation by the accepted standards of care in women prior to the menopausal transition, says Randolph.  These data can be used to explain why clinicians may suggest watchful waiting during the transition.”

“However, as the paper’s authors point out, pathology reports were not available, so neither women nor clinicians should fail to disucss bleeding patterns in perimonopause, states Margery Gass, MD, NCMP, executive director of the North American Menopause Society in Mayfield Heights, OH.  Clinicians must use good judgment in deciding when to try hormonal contral of the bleeding and when to evaluate the endometrium, she notes.”

“The current paper’s findings might help clinicans reduce the numbers of endometrial biopsies performed on perimenopausal women who have single episodes of heavy or prolonged bleeding, says Anita Nelson, MD, professor of the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles.”

According to Nelson, the current paper’s findings follow in the same line as research published in 2010, which showed that the highest blood losses are seen in late menopausal transition with ovulatory cycles high estradiol levels. 3  Nelson also points to a 2012 publication, where in a survey of 2,051 naturally menstruating women, two-thirds reported heavy menstural bleeding in the previous six months.  Follow-up showed that 30% of the remaining third developed problems in the next two years, which indicates heavy menstural bleeding to be a very common problem indeed, Nelson notes. 4

Per Susan Wysocki, WHNP-BC, FAANP, president and chief executive officer of iWomensHealth in Washington, DC, questions about bleeding can become so routine that important information might be lost if additional information isn’t elicited.  “What has changed about your menstrual bleeding pattern since your last visit?  What do these changes mean to you?”  Each woman is going to have a different concept of what the changes mean to her life, says Wysocki.

It also is important to consider that some bleeding might not be related to the transition into menopause and should be investigated, because it could be related to some pathology or sexually transmitted infection. 

 Hormonal contraceptive methods can be important options in managing bleeding, notes Wysocki.  No contraceptive method is contraindicated based on age alone; however, estrogen-containing methods should be reserved for women without cardiovascular or thrombotic risk factors.

The levonorgestrel intrauterine system has particular benefits during perimonopause and is safe for use in nearly all women. 5  Use of the device is approved for treatment of heavy menstrual bleeding, a common concern during the perimenopaus.

Here is how to order subscriptions to Rebecca Bowers “Contraceptive Technology Update”:Customer Service: (800) 688-2421 or fax (800) 284-3291.  Email: Hours of operation: 8:30a.m.-6 p.m. Monday – Thursday.  8:30 a.m.-4:30 p.m. Friday, EST.Discounts are available for group subscriptions, multiple copies, site-licenses or electronic distribution.

Robert A. Hatcher MD, MPH

Emeritus Professor of Gynecology and Obstetrics

Emory University School of Medicine

Atlanta, GA

July 2, 2015, July 13, 2015, July 29, 2015, Updated August 21, 2015

Key Words:  Contraceptive Technology Update, menopausal transition, counsel, bleeding patterns, Dr. Sioban Harlow, menstrual cycles, dramatically, Rebecca Bowers, heavy bleeding, Dr. John Randolph Jr., periods, hormonal control, evaluate, endometrium, endometrial biopsies, premenstrual, Dr. Anita Nelson, ovulation, estradiol levels, Susan Wysocki, sexually transmitted infections, estrogen, cardiovascular, thrombotic risk factors, levonorgestrel intrauterine

To learn more about the advantages and disadvantages of all available contraceptive methods, go to:   You can order all of these books listed below from our website or by calling 404-875-5001.       


  1. Hale GE, Manconi F, Luscombe G. et. al. Quantitative measurements of menstrual blood loss in ovulatory and anovulatory cycles in middle-and late-reproductive age and the menopausal transition. Obstet Gynecol 2010; 115(2 Pt 1): 249-256
  2. Shapley M, Blagojevic M, Jordan KP, et al, The spontaneous resolution of heavy menstrual bleeding in the premenopausal years. BJOG 2012;110(5): 545-553
  3. 5. Baldwin MK, Jensen JT. Contraception during the perimenopause. Maruritas 2014;76(3): 235-242 

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Posted on

July 14, 2015