As San Diego-based OB-GYN Dr. Diana Hoppe explains, menopause is “when a woman goes from a reproductive stage to a non-reproductive one,” with the average age around 51. 

Perimenopause, Dr. Hoppe notes, is the “2-8 years before menopause when a woman is still experiencing a menstrual cycle.” During this time cycles can become more irregular, i.e. they can happen twice a month or they can skip altogether. 

She says both perimenopausal and menopausal women can experience shared symptoms including hot flashes, night sweats, mood swings, insomnia, and decreased libido. So, how exactly does spotting factor in when it comes to menopause, and when should there be cause for concern?

When spotting happens during perimenopause. 

Irregular bleeding and spotting are very common when it comes to perimenopause. This is because there are usually 1-3 years of irregular periods during this time, which can include spotting, explains Houston-based OB-GYN Dr. Susan Hardwick-Smith. 

During perimenopause, “many women experience changes in their bleeding patterns, which can include spotting around ovulation,” says Dr. Yael Swica, a women’s health doctor from New York City. This spotting can occur leading up to their periods, or afterward. 

Dr. Swica says women can also experience heavier periods or changes in cycle length during this time as well. 

This is not normal, however, during menopause. When it comes to menopause, Dr. Hoppe puts it simply: “a woman should not have any bleeding or spotting.”

When spotting happens during menopause.

If bleeding or spotting occurs at any point during menopause, a woman needs to be seen by her doctor. During your visit, there will likely be a pelvic ultrasound and a possible biopsy of the uterine lining (known as an endometrial biopsy). Dr. Hoppe explains that this is “to rule out any precancerous conditions.” 

“If a woman is menopausal, she should not have spontaneous bleeding,” Dr. Hoppe says, adding, “Sometimes [bleeding] might be due to a thyroid abnormality.” Signs of anemia and fatigue, along with spotting or bleeding, is also cause for concern and lab tests should be performed.

How to manage bleeding during perimenopause.

Again, if you’re bleeding during perimenopause, you’ll want to see your doctor, but for women who experience bleeding or spotting during menopause, there are ways to manage. 

Pads and/or tampons may still be needed, especially for an unusually heavy menstrual cycle, Dr. Hoppe says. 

“There is also a procedure called endometrial ablation, which can help with heavy bleeding in perimenopausal women,” she adds. 

For some postmenopausal women on hormone therapy, sometimes a progestin-IUD can be used to help bleeding, Dr. Hoppe says, but only after a complete workup has been done to rule out any abnormalities.

Other bleeding during perimenopause and menopause.

“Sometimes spotting can occur due to vaginal dryness and/or pain with intercourse and a woman may notice spotting after sexual intercourse,” says Dr. Hoppe. 

If bleeding occurs with/after sex for perimenopausal women, Dr. Hoppe explains that this may be due to vaginal atrophy. “A gynecological exam should be done to make sure there are no vaginal lesions, lacerations or cervical polyps, which might be causing bleeding with sexual intercourse.” 

Another thing to be aware of? “Thinning of the vulvar and/or vaginal tissue is very common during menopause, and even during perimenopause,” says Dr. Swica. 

During this time, she explains, the “tissue can become more fragile and, therefore, more vulnerable to injury from contact that previously caused no injury.” This can be treated with estrogen, Dr. Swica notes, as well as other non-hormonal options. 

This is notable because, as Dr. Hoppe explains, “Sometimes a woman may experience vaginal bleeding or spotting when starting hormone therapy.” This should be managed by a physician well-versed on types, routes, and dosages of hormone therapy to help adjust for correct dose, she adds.

What your bleeding can tell you about menopause and perimenopause.

One of the biggest misconceptions held by women cycling in their 40s, and 50s (or sometimes even their 30s) is that their worsening PMS symptoms have nothing to do with menopause. Dr. Swica notes that because perimenopause is a “multi-year process,” those symptoms (like vaginal dryness or weight gain) can actually begin long before your last period. 

By paying attention to these symptoms, Dr. Swica says that you and your doctor should be able to discuss options and medications that can ease your transition into menopause.