We need to talk about perimenopause periods
There have been few things in my life as predictable as my period. I track it with an app and it arrives exactly when it should – the same flow each month. That is, until a few months ago, when it went rogue – arriving earlier, suddenly much heavier. I presumed it was a one-off, but my confusion deepened the following month when it once again came early – this time, inconveniently, during a dinner party.
Thanks to a helpful host, I was fine – more importantly, so was my dress – but later that night I descended into a Google hole to figure out what on earth was going on. And as I typed in ‘Periods shorter and heavier, 42 years old’, it pointed to one thing: perimenopause.
I always thought the approach to menopause meant fewer periods; I never considered they could get heavier or more frequent first. Yet one in five British women will suffer from heavy periods in the run-up to menopause.
And, for some, they will be so heavy they can impact daily life. This might include soaking through tampons or pads and having to change them every hour, passing large clots or having sudden floods of blood. Sometimes, heavy periods can cause anaemia, bringing with it fatigue, weakness and shortness of breath. And, in extreme situations, they might lead to hospital admittance and the need for blood transfusions.
Often, people are unaware that they don’t have to put up with this. Instead, they shape their lives around the deluge – staying at home, avoiding places without toilets, cancelling plans...
The stigma around perimenopause periods
While it’s true we’re talking about menopause now more than ever and having frank conversations about hot flushes, meno-rage and brain fog, something that’s not discussed as openly – certainly not so directly – are the periods themselves. The blood. Which, when it comes to perimenopause, can be abundant.
In a recent Goop podcast episode with Halle Berry, Gwyneth Paltrow herself – often seen as a wellness trailblazer– spoke of feeling ‘alone’ after a ‘bizarre’ year of irregular periods, which could come every two weeks then skip a month, then be so heavy she needed an intravenous (IV) iron infusion. ‘I don’t know what the f**k is happening,’ she said.
‘You might think everyone’s talking about the menopause but, actually, there’s still a huge lack of awareness,’ says Dr Philippa Kaye, author of The M Word: Everything You Need To Know About The Menopause. ‘And in some communities and demographics, it’s greater than others, so there’s a huge need for education.’
On average, menopause – the 12-month point after you’ve had your final period – occurs between the ages of 45 and 55, with the UK’s average age for menopause being 51. But perimenopause – the transition towards menopause– can last anything from a few months to more than a decade, though the average time is around four years. And it can cause period havoc.
What causes shorter, heavier periods during perimenopause?
From as early as your late 30s and early 40s, the ovaries can begin to work less efficiently than usual. As a consequence, this can cause the body to ramp up on hormones to try to help the ovaries maintain egg production.
Cycles may at first get shorter by a few days, and other symptoms might appear, even if the menopause is years away. Heavier periods are often the result of these erratic hormones impacting the process that builds, breaks down and repairs the lining of the womb (the endometrium).
But age can also play a part, as it increases the likelihood of developing fibroids (benign growths) and adenomyosis, where the lining of the uterus starts growing into the muscle in the wall of the womb – both of which can cause heavy, painful and prolonged menstrual bleeding.
In her new book, Blood: The Science, Medicine And Mythology Of Menstruation, gynaecologist Dr Jen Gunter describes the transition to menopause as ‘hormonal chaos’, where oestrogen levels may be ‘low, normal or even high, and progesterone levels may be low or normal.
Cycles can be as usual, or they can be shorter or longer. Even when they appear to be a normal length, the seemingly punctual bleeding may be from a cycle without ovulation.’ In fact, ‘when you’re in the menopause transition,’ she says, ‘the only thing to expect, hormone-wise, is the unexpected.’
Given many women have spent some 20 years getting familiar with their monthly cycle, this midlife shift can be hugely unsettling.
‘As someone who has been as regular as clockwork my whole life, it’s been really disconcerting to be “off schedule”,’ says Hannah Jones, 43. ‘And my periods are way heavier and shorter than they ever were, so it’s like five days’ worth of blood in just 36 hours. I’ve had to use period pants as well as tampons on many occasions.’
For other people, like Talia Clark, 47, the shock of these changes has been compounded by not feeling heard: ‘At 40, my periods were every three weeks and heavy, which was tiring. I ended up seeing several specialists over the years, but the first gynae I saw said – and I quote – “I was having a rip-roaring cycle”, that these hormonal changes were common, and sent me on my way. We’re told that menopause is something that happens when we’re “older” – I was not prepared for the changes to happen as early as they did for me.’
As teenagers, early periods often come hand in handwith unpredictability, insecurity and adolescent hormonal havoc. And yet, the female reproductive system concludes in a similar way, except older women have largely been expected to stay silent about this significant physiological shift.
Perimenopause and menopause involve ‘an enormous amount of hormonal and physical changes, and yet we seem to be much kinder and more understanding towards our teenagers than we, or society, are to ourselves when going through these changes,’ says Dr Kaye.
There’s no denying that taboo still shadows so much of women’s health. A survey by The Fawcett Society of 4,000 perimenopausal and menopausal women found that 45% had never talked with their GP about symptoms. Even among those with five or more severe symptoms, 29% had not spoken to anyone at their GP practice about menopause.
‘In my late 40s, my periods went from being regular and light to very heavy and unpredictable. They were very heavy for about two years, but I didn’t see a doctor– I didn’t even think about getting help, to be honest,’ says Jo Moseley, now 59, who adds that ‘postmenopause is an utter joy on the period front.’
One in four women will not have symptoms of the perimenopause, but for the remaining 75%, ‘if you’re struggling, talk to your doctor,’ says Dr Kaye. ‘You shouldn’t have to put up with anything. But what is really important is knowing what is normal for you. Unless you do, you can’t tell what is abnormal.’
Dr Kaye recommends using a tracker to maintain a sense of what’s going on (or not), and when/for how long. Ideally record not just period start dates and heaviness, but any other symptoms, including mental health and mood changes, flushes, fatigue and insomnia, too.
Additionally, pay attention to ‘any inter-menstrual bleeding, such as bleeding in between your periods, bleeding after sex or bleeding after the menopause, which must be checked out, too.’
How to treat perimenopause bleeding
When it comes to treatment, age will determine the initial steps. ‘If you’re over 45, we’ll go on your symptoms alone, but under 45, we tend to do blood tests – and definitely under the age of 40 – because there are lots of reasons why your periods might become irregular,’ says Dr Kaye, citing low thyroid hormones, for example, as a possible cause for heavy periods.
And just as everyone’s perimenopausal journey will be different, so too will the solutions that support a smooth transition. Hormone replacement therapy (HRT) can be taken even if you still get periods, and involves either taking oestrogen and progestogen (combined HRT) or just oestrogen, if you’ve had a hysterectomy.
Viewed by many as a panacea for perimenopause and menopause, uptake of HRT has been rising for several years, with more than double the number of patients using it in 2022 to 2023 compared with 2015 to 2016.
However, HRT in perimenopause can also cause temporary period changes in some – irregular bleeding, unscheduled bleeding and heavy bleeding can occur up to six months after taking it. For some women, two periods a month can even become the ‘new normal’ until things settle down.
‘Irregular bleeding or spotting can be common in the first three months after starting HRT, but after that point it should always be assessed,’ says Dr Kaye. Doses may need to be tweaked after a few months until you find the right fit for you.
If your only midlife symptom is heavy bleeding, you might first consider something such as tranexamic acid instead – a medicine that helps control bleeding – or perhaps the contraceptive pill or the Mirena coil – a small, T-shaped plastic device that’s put into your womb and releases progesterone.
Studies have found that after one year’s use of the coil, 90% of women have no bleeding at all, although bleeding and spotting may initially increase in the first three to six months of having the implant.
And the importance of openness and communication can’t be underestimated. ‘We know that in cultures where the menopause and growing older is viewed positively, women seem to have fewer symptoms,’ says Dr Kaye. ‘The messaging about menopause for millennia has been that it’s a full stop. But, actually, maybe the menopause is freedom.
‘It’s – eventually – freedom from heavy, painful periods; for many, growing older means freedom from the burden of the early childcare years. And, in some cultures, women are able to do things that they weren’t able to do when they were bleeding. We’re going to live a third of our lives in a postmenopausal state – we can live that happy, healthy and wise.’
In the meantime, though, it’s important to keep up the perimenopause conversation – especially one that starts: ‘I’d like to talk about menstrual bleeding.’ Which is exactly what I will be saying when I call up my GP later today. Because if your periods do the unexpected and start causing havoc, defy the statistics and don’t stay silent.
Three ways to prepare for perimenopause periods
Try this iron-rich, herbal blend to help reduce tiredness and fatigue – common with heavy periods.
From light to heavy absorbency, feel more confident with leakproof underwear.
Track periods and symptoms with this app, created by renowned menopause specialist Dr Louise Newson.
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