Perimenopause Spotting: What's Normal and What to Investigate

Intermenstrual bleeding: Bleeding occurring between menstrual periods, distinct from the expected period. In perimenopause, can be caused by hormonal changes affecting the uterine lining shedding timing, but also by structural causes (polyps, fibroids, endometrial changes) that require investigation.

Postcoital bleeding: Bleeding after sexual intercourse. In perimenopause, can be caused by vaginal atrophy (thinning and fragility of vaginal walls from estrogen decline) or by cervical or endometrial conditions. Postcoital bleeding always warrants medical evaluation to exclude cervical pathology.

Abnormal uterine bleeding — including intermenstrual spotting — is one of the most common reasons for gynaecological consultation in perimenopausal women

Source: Munro MG et al., 2018 — FIGO Classification System for Causes of Abnormal Uterine Bleeding (PALM-COEIN), International Journal of Gynaecology and Obstetrics

What Causes Perimenopause Spotting?

Light bleeding between periods during perimenopause can arise from several sources:

Hormonal instability: Anovulatory cycles produce estrogen-only stimulation of the uterine lining without progesterone opposition. This can cause the lining to become unstable and shed at unpredictable times, producing breakthrough spotting.

Uterine polyps: Endometrial polyps are benign growths on the uterine lining, very common in perimenopause. They can cause irregular spotting, heavier periods, and bleeding between periods. They are easily identified on transvaginal ultrasound.

Fibroids: Uterine fibroids (benign muscle tumours) are extremely common in perimenopausal women. Depending on location, they can cause irregular bleeding and spotting.

Vaginal atrophy: Thin, fragile vaginal walls from declining estrogen can bleed with minor friction — noticeable after sex or physical activity.

Cervical causes: Cervical ectropion or, importantly, cervical dysplasia and cancer can cause spotting. Cervical screening (smear test) should be up to date.

The Investigation Process

Recurrent spotting requires gynaecological evaluation. The assessment typically includes:

Cervical examination and smear: Excludes cervical causes
Transvaginal ultrasound: Assesses uterine structure, identifies polyps, fibroids, endometrial thickness
Endometrial biopsy: May be recommended if the lining appears thickened or if risk factors are present

Postmenopausal Bleeding: Prompt Evaluation Always

Any bleeding more than 12 months after the last period is postmenopausal bleeding. This requires evaluation within 2 weeks to exclude endometrial cancer. The vast majority of postmenopausal bleeding is caused by benign conditions, but the investigation must be done to confirm this.

Q&A

Is spotting between periods normal in perimenopause?

Light, occasional spotting can occur in perimenopause due to hormonal fluctuations affecting the uterine lining. However, intermenstrual bleeding is also a symptom of polyps, fibroids, endometrial hyperplasia, and cervical changes. Recurrent spotting, heavy spotting, or bleeding after sex warrants evaluation — it should not be assumed to be purely hormonal.

Q&A

What causes spotting in perimenopause?

Hormonal causes: anovulatory cycles producing estrogen-only stimulation of the lining, which may break through at unpredictable times. Structural causes: uterine polyps (very common in perimenopausal women), fibroids, endometrial hyperplasia. Vaginal causes: vaginal atrophy causing vaginal wall fragility. Cervical causes: require examination to exclude.

Q&A

When does perimenopause spotting need medical evaluation?

Evaluation is appropriate for: recurrent spotting on more than one or two occasions, spotting that is more than very light, bleeding after sex (always investigate), any bleeding after 12 months without a period (postmenopausal bleeding requires prompt evaluation), or spotting with pelvic pain.

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What investigations are done for perimenopause spotting?

A GP assessment including: pelvic examination, cervical smear if overdue, transvaginal ultrasound to assess the uterus and endometrium, and consideration of endometrial biopsy depending on ultrasound findings and risk factors. These investigations differentiate hormonal from structural causes.

Is postmenopausal bleeding an emergency?

Any bleeding occurring more than 12 months after the last period should be evaluated promptly — within two weeks is appropriate in most healthcare systems. The most concerning diagnosis to exclude is endometrial cancer, which is highly treatable when detected early. Most postmenopausal bleeding has benign causes (atrophy, polyps) but prompt investigation is essential.

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