Ask Dr. Pat · Health

Perimenopausal Heavy Bleeding: Is It Normal?


  1. Remember that heavy vaginal bleeding is not normal.  If you soak through two pads or tampons in two hours in a row, call your healthcare provider or go to the emergency department. Bleeding this heavily can be serious or even life threatening.
  2. Since the heavy bleeding has resolved for now, see a gynecologist urgently and discuss the outlined diagnostic steps for evaluation of the heavy bleeding.  If the evaluation confirms that you have no other cause for infrequent periods and this one extremely heavy period, choose a plan to prevent heavy bleeding. For outpatient management of acute abnormal uterine bleeding, hormonal therapies are first-line choices. Progestin-only methods are at least as effective as estrogen-progestin therapies (oral contraceptive pill) for the control of one episode of heavy bleeding. A short-term (1 month) oral high-dose progestin-only treatment with medroxy progesterone acetate is often an effective first treatment. Oral contraceptive pills work very effectively in the right dose for most cases of uncomplicated perimenopausal heavy bleeding and may also control the immediate problem.
  3. Longer term solutions for this perimenopausal anovulatory bleeding include a progestin coated intrauterine device or the oral contraceptive pill in carefully evaluated patients. Levonorgestrel-releasing IUDs (brand names Mirena, Kyleena, Skyla, and Liletta) prevent heavy bleeding by thinning the endometrium (the lining of the uterus). Although IUDs can be removed at any time, the Mirena and Kyleena IUDs last for at least five years and the Skyla and Liletta IUDs last for three years. Some women completely stop having menstrual periods while using a levonorgestrel-releasing IUD; this is not harmful and does not require treatment. Menstrual periods will return when the IUD is removed. The IUD has the added benefit of contraception, which you still need.
  4. The oral contraceptive pill has been a great favorite of gynecologists and the pharmaceutical industry for the treatment of heavy, frequent and otherwise abnormal bleeding in women in their 40s and sometimes even in their 50s. I do not recommend this form of hormonal treatment in women past age 45, unless it is used for a brief period to control heavy bleeding (no more than a few months). If this form of hormonal management of heavy bleeding is chosen to control perimenopausal heavy bleeding, then there needs to be a  careful  review of past medical history, family history and blood tests that evaluate each woman’s risk for blood clots, in order to determine if she has a greater risk of a blood clot, stroke, or cardiovascular event than the average woman of this age. The oral contraceptive pill is a great form of contraception for young women and even some women in their forties, as long as doctor and patient understand that there are clear contraindications to the use of the birth control pill, and that these should never be ignored. These pills contain estrogen and progestin, so the impact on breast cancer risk in an older woman must always be considered. No woman over 40 should start an oral contraceptive pill for an extended period without a current mammogram and a normal clinical breast exam.
  5. If the IUD or oral contraceptive pill fails to control the heavy bleeding, surgical options will need to be considered.
  6. Begin an iron supplement (iron sulfate or gluconate taken with Vitamin C to enhance absorption is a good choice) one to three times a day, depending on your tolerance for its side effects (largely constipation). Do not take the iron supplement within four hours of calcium or dairy products, since calcium and iron bind together in the gut and are not absorbed. Continue the iron supplement until you are one year without menstruation. There is now an intravenous form of iron for patients who cannot tolerate iron supplements by mouth.
  7. Start a nonsteroidal anti-inflammatory drug—for example, 800 mg of ibuprofen—three times a day with food just for the time you are bleeding (unless you have a contraindication to the use of these over-the-counter drugs). These drugs are effective in many cases of moderate bleeding when no other cause is found. Take this dose of ibuprofen before the onset of bleeding if possible, and continue until the bleeding stops. It has the added benefit of diminishing period pain.


These are the first-line treatments for a woman your age who has experienced her first episode of severe vaginal bleeding after no menstrual cycles for a few months. You know a great deal now about the importance of a good history, complete physical exam, appropriate diagnostic workup and treatment options that are effective. You should actively participate in the decisions for evaluation and treatment as you develop a relationship with the new gynecologist.

Physiological change in the menopausal transition will cause many alterations in hormonal, physical and emotional aspects of life, but it is not the cause of every symptom in a woman past age 40. New symptoms must always be evaluated.

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