Ask Dr. Pat · Health

Perimenopausal Heavy Bleeding: Is It Normal?


The simple diagnostic steps  for the first episode of heavy bleeding are:

  • A careful history that includes symptoms like fatigue, dizziness, easy bruising, new nosebleeds, or bleeding from the gums can provide important diagnostic clues. Family history of malignancy or bleeding disorders will be important.
  • A thorough physical and pelvic exam is next. These are the talents of a decent diagnostician: take a complete history and do a thorough physical exam. The pelvic exam sometimes reveals a benign mass that can be removed, such as a polyp or fibroid pushing out of the endocervical canal and putting stress on its blood supply, causing a first episode of bleeding. In addition, cervical cancer can be an unlikely but deadly cause of heavy bleeding. If a patient has had normal pap smears in a timely fashion, it is extremely unlikely that cervical cancer would be the cause of this kind of bleeding.
  • Pregnancy test. Yes, I know that pregnancy is unlikely at age 46, but it does happen. Ectopic pregnancy or incomplete miscarriage must not be missed.
  • Pelvic ultrasound.  This test can diagnose an abnormality in the uterine cavity, such as a polyp, fibroid, or thickening in the lining of the cavity. Ovarian cysts and abnormalities of the uterus can be diagnosed effectively with an ultrasound as well. All of these may be the cause of, or contribute to, this problem of serious menstrual bleeding.
  • Blood tests to evaluate for anemia, iron levels, and bleeding disorders, along with liver function tests, thyroid function. Blood tests for ovarian hormones: estradiol and progesterone along with pituitary hormone levels for FSH and LH. These will help with both diagnosis and the development of a treatment plan.
  • Evaluation of endometrial tissue may be considered based on your gynecologist’s evaluation: a biopsy of the tissue inside of the uterus, called an endometrial biopsy. This can be  done in the office or in some cases a hysteroscopy  may be recommended, which uses a small telescope to look inside the uterus.



If no abnormalities are found on the physical exam, no unexpected medical problems are diagnosed, your blood tests do not reveal a pregnancy, bleeding disorder, or other gynecologic problem that can contribute to heavy vaginal bleeding, and if the pelvic ultrasound reveals normal endometrial thickness and no other abnormalities then the working diagnosis is likely to be the one you expected: abnormal bleeding during the perimenopause. We refer to this as anovulatory bleeding. Anovulation occurs when your ovaries do not produce and release an egg (ovulate) once a “month.” This causes your menstrual period to be irregular or absent. Anovulation is common in adolescents and in women who are near menopause. Anovulatory bleeding simply means that when a woman misses her period for several months in this hormonal stage, then it’s likely that she has not ovulated. As the ovaries age, ovulation occurs less frequently. But the ovaries still produce estrogen, often in very high levels at some stages of the menopausal transition. During this time, the lining of the uterus is constantly exposed to various levels of estrogen alone. Without the support of ovulation that allows the ovaries to deliver progesterone to the endometrium, the lining of the uterine cavity becomes unstable, and bleeding that is heavy and long often occurs.

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