Coping with Heavy Periods During Perimenopause

If your periods have always been pretty predictable, it can be a worry when things suddenly change.

For women entering perimenopause, dramatic differences in the flow and duration of their periods are common. This can have a significant impact on physical health, emotional well-being, and overall quality of life.

In this article, we discuss how your period can change during this stage of life, how to manage heavy menstruation (periods) in perimenopause/menopause, and when to speak to your doctor about your symptoms.

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Normal vs abnormal bleeding

Although there can be differences between individuals, a typical period:

Occurs every 21-35 days
Lasts between 2 and 7 days
Has heavier bleeding in the first 2 days
Produces red blood when heaviest and pink or brown blood on lighter days
Causes 20 to 90ml of blood loss (1)

1 in 3 women will describe their periods as heavy and 1 in 20 women aged between 30-49 see their GP every year for heavy periods. Heavy periods can also be referred to as heavy menstrual bleeding or menorrhagia (2).

It is not unusual to experience heavy menstrual bleeding in perimenopause due to the fluctuating hormone levels however any new changes to your periods should be discussed with your doctor.

Perimenopausal hormonal changes can lead to erratic and unpredictable bleeding and may cause longer or shorter cycles as well changes to period flow.

As you get older, you may not release an egg every cycle; this is called an anovulatory cycle. Normally, this release of an egg triggers progesterone release, which controls the thickness of the womb lining. Without an egg being released from the ovary, both oestrogen and progesterone can vary dramatically, resulting in irregular, heavier bleeds alongside menopausal symptoms.

Hormonal fluctuations can cause bleeds in perimenopause to be:

Shorter or longer
More irregular
Skipped
Lighter
Different from usual in colour

Find out more in our guide to perimenopause.

What counts as heavy bleeding?

Heavy menstrual bleeding during perimenopause can look different for everyone. Some people experience sudden, intense episodes of flooding, while others may have prolonged periods that seem to go on for weeks. It’s also possible for periods to vary drastically from cycle to cycle and the unpredictability of these changes can be distressing.

Medical treatments and heavy bleeding

There are many options when it comes to helping heavy or painful periods in perimenopause, including both hormonal and non hormonal treatments.

Hormone replacement therapy

Hormone replacement therapy (HRT) can help regulate bleeding in perimenopause when periods are becoming spaced out and erratic by giving a scheduled withdrawal bleed once a month. This may be by either using sequential combined HRT alone, by using HRT alongside contraceptive methods e.g. progesterone only pill, or using a Mirena coil as part of your HRT regime.

Learn more about bleeding on HRT.

Contraceptives

Hormonal contraceptives can be an effective way to manage heavy periods in perimenopause while also providing birth control.

Mirena coil

The Mirena coil, a hormonal intrauterine system (IUS), releases a small amount of progestogen directly into the uterus. This helps to thin the uterine lining, leading to lighter periods or, in some cases, stopping them altogether. Evidence demonstrates that the Mirena coil significantly reduces monthly blood loss in 9 out of 10 women (5). It also provides a continuous progesterone option for the progesterone component of HRT.

Combined oral contraceptives

The combined oral contraceptive pill (COC) contains both oestrogen and progestogen and can help regulate periods, reduce menstrual flow by up to 40%, and ease symptoms such as cramping (11)It’s often used in perimenopause to provide cycle control and can also be used to help PMS and endometriosis. However it may not be suitable for those at higher risk of blood clots or other health conditions (6).

Learn more about how contraception is used during menopause.

Progesterone only contraceptives

The progesterone only pill (POP) prevents ovulation (an egg being released by the ovaries) and prevents growth of the lining of the uterus as a form of contraception. It is also known as the mini pill. This can be used alone or alongside HRT to help with bleeding and perimenopausal symptoms whilst also providing contraception. It can be used to help heavy periods and endometriosis (4).

Medication

For those who prefer non-hormonal options, certain medications can help reduce heavy menstrual bleeding.

Tranexamic acid

Tranexamic acid is a non hormonal medication that helps blood clot and can reduce menstrual blood loss by up to 50% (7). It’s usually taken three times a day for up to 4 days from the start of your period (8, 15).

Nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen or mefenamic acid, can help decrease blood flow while also relieving period pain. They work by reducing prostaglandin levels, which play a role in heavy bleeding and cramping (9).

Surgery

Surgical options may be considered when other treatments haven’t been effective or when heavy bleeding significantly impacts quality of life. However, they are not usually the first line of treatment.

Endometrial ablation

Endometrial ablation is a minimally invasive procedure that removes the uterine lining to reduce or stop periods (10).

Hysterectomy

Hysterectomy, the surgical removal of the uterus, is a permanent solution to heavy bleeding. It is typically only recommended in severe cases, particularly when other treatments have failed, or when conditions such as fibroids or adenomyosis contribute to excessive menstrual flow (10).

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When to seek emergency care vs a routine check

Although changes to periods occur in perimenopause is common, you should always talk to your doctor about bleeding changes, as it can sometimes be an indication of an underlying health issue, including:

Polyps
Endometrial hyperplasia
Fibroids
Adenomyosis
Pelvic inflammatory disease
Sexually transmitted infections
Polycystic ovary syndrome (PCOS)
Thyroid disease
Inflammation of the cervix (cervicitis)
Uterine or cervical cancer, although this is rare (3,11)

Other changes to bleeding patterns that need review with your doctor include:

Bleeding or spotting after sex
Bleeding or spotting between periods
Inconsistent or unpredictable cycles
Significant changes to bleeding heaviness
Going without a period for 3 months or longer

You should seek immediate medical attention if you have heavy uterine bleeding in perimenopause and:

You have extreme pelvic pain
Find a new abdominal or pelvic lump
Bleeding is severe enough to cause weakness or lightheadedness
You are short of breath or are experiencing chest pain
Bleeding is accompanied by fever
Your symptoms become more severe (12)

How to manage heavy periods during perimenopause

Dealing with heavy periods isn’t easy and it can sometimes feel like this symptom, along with other changes during menopause, are significantly impacting your quality of life.

Below are some practical steps that may help.

Use high-absorbency period products, such as super tampons, overnight pads, menstrual cups, or period underwear.
Keep a spare change of clothes and extra period products in your bag or at work in case of flooding.
Place a towel or waterproof mattress protector on your bed for added security.
Stay hydrated and eat iron-rich foods such as red meat, leafy greens and beans, to prevent iron deficiency. A tailored menopause diet can help and contribute to enhanced overall wellbeing.
Keep a menstrual diary or use a period-tracking app to monitor cycle changes and identify patterns.
If possible, adjust your schedule to include more rest on days when you typically experience the heaviest flow.
Use heat therapy, such as a heating pad or hot water bottle, to relieve cramps and discomfort.
Practice gentle exercise, like walking or yoga, which may help with circulation and symptom relief. Yoga during the menopausal transition has numerous other benefits too.

Long-term health implications of heavy bleeding in perimenopause

Heavy periods during perimenopause can have long-term health implications, particularly if they go unmanaged.

Iron deficiency anaemia

Chronic heavy blood loss can lead to iron deficiency anaemia, causing:

Fatigue
Weakness
Dizziness
Heart palpitations
Shortness of breath
Headaches
Pale skin (13)

A full blood count test can determine if you have anaemia, and it can be treated with iron tablets. If left unmanaged, iron deficiency anaemia:

Can increase your risk of illness and infection as low iron levels affect the immune system.
May increase your risk of developing complications that affect the heart or lungs, including an abnormally fast heartbeat or heart failure (13).

Mental health effects

Very heavy periods in perimenopause can also have a profound effect on your mental health, relationships, and quality of life.

Women who have heavy menstrual bleeding:

Can experience anxiety and depression
Are more likely to avoid activities
Are more frequently absent from work
Feel they get less done
Feel less feminine (14)

Find out more about the relationship between anxiety and perimenopause, and what can help.

In summary, heavy periods are a common occurrence for perimenopausal women due to hormonal fluctuations, but that doesn’t mean you have to navigate them on your own.

Monitoring heavy periods is essential for understanding changes in your cycle and identifying any potential underlying health concerns. Keeping track of your flow, clot size, cycle length, and any symptoms like fatigue or dizziness can help you recognise patterns and discuss them with a healthcare professional.

If you’re experiencing significant period changes during perimenopause that are affecting your daily life, don’t hesitate to seek medical advice. Support and treatment options are available to help you manage your symptoms and protect your long-term health. At Menopause Care, we have a team of specialists here to listen to your concerns, provide evidence-based resources, and develop a personalised care plan based on your unique symptoms and circumstances. To get started, book a consultation with a menopause doctor.

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DisclaimerAt Menopause Care, we ensure that everything you read in our blog is medically reviewed and approved. However, the information provided is not meant to replace professional medical advice, diagnosis, or treatment. It should not be relied upon for specific medical advice.

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