Bleeding for weeks in perimenopause

Is it normal to bleed for 2 weeks in perimenopause?

It is common, and it is also abnormal in the medical sense, which is why the two answers people find online seem to contradict each other. A 2018 review of the menopause transition found a high chance of excessive and prolonged bleeding in the years close to the final period. So a two-week bleed in your late 40s has an ordinary explanation more often than not.

The guidelines draw the line much earlier than two weeks. The American College of Obstetricians and Gynecologists (ACOG) says a normal period generally lasts up to 7 days and lists bleeding for longer as abnormal uterine bleeding. The NHS counts a period of more than 7 days as a heavy period. ACOG's guide to bleeding in perimenopause adds a test that fits this stage well: bleeding that lasts longer than usual for you. By either measure, a period still going on day 15 is well past the line.

Why a period can last for weeks

The usual cause is a cycle without ovulation. ACOG's page on endometrial hyperplasia explains the chain. Oestrogen makes the womb lining grow. After an egg is released, progesterone rises, and when it falls again the lining sheds as a period. If no egg is released, no progesterone is made and the lining is not shed on schedule. It keeps growing under oestrogen and then breaks down unevenly, which can mean a long, heavy or stop-start bleed.

Perimenopause is exactly the stage when ovulation becomes patchy. Some months an egg is released and some months it is not, so a normal five-day period can be followed by a three-week one. The same patchy ovulation is behind the shifting gaps described in our guide to irregular periods in perimenopause.

15 days and still bleeding: what to count

Before the appointment, it helps to know which of three patterns you have, because a doctor will ask:

• One long period: bleeding starts like a period and does not stop, sometimes heavy for days and then light for a week or more.
• Periods that come too close: a period ends and another begins within days. ACOG treats cycles shorter than 21 days as abnormal, counted from the first day of one period to the first day of the next. Our page on two periods in one month covers this pattern on its own.
• Constant or on-and-off bleeding: light bleeding or spotting most days, with heavier days mixed in. Spotting between periods has its own causes, listed in our guide to spotting between periods.

For any of them, count day 1 as the first day of real bleeding, and write down every day you bleed with a flow word: spotting, light, medium or heavy. ACOG uses those four words, and a doctor can read a list of them quickly.

A period for 3 weeks with clots

Clots on the heaviest days of a long bleed are common, because blood that collects quickly in the womb thickens before it leaves. The size is what matters. The NHS lists clots larger than about 2.5 cm, the size of a 10p coin, among its signs of heavy bleeding, and ACOG gives the US quarter as its yardstick. Three weeks of bleeding with clots that size is heavy bleeding as well as long bleeding, and both belong in the same conversation. Our article on heavy periods and blood clots has the full list of measured signs.

Weeks of blood loss can also drain the body's iron. ACOG notes that a complete blood count can show anaemia, and the NHS includes feeling tired or short of breath a lot in the same list. If you are worn out after weeks of bleeding, say so at the appointment instead of putting it down to poor sleep.

When to get help the same day

ACOG says to seek emergency care right away if you are changing pads or tampons every hour for more than 2 hours in a row and you also have chest pain, shortness of breath, or feel lightheaded or dizzy. A long bleed can turn into this kind of acute bleed, and it is treated first and investigated afterwards.

Pregnancy is still possible in perimenopause, because ovulation can continue right up to the final period. Unusual bleeding with a missed or late period and pain low in the tummy can be an ectopic pregnancy, which the NHS treats as an emergency. A pregnancy test at home is a quick first step if there is any chance of it.

And if you have already gone 12 months without a period, any bleeding at all needs checking, light or heavy, short or long.

Why doctors check prolonged bleeding

Most long bleeds in perimenopause come from the hormone swings described above. Doctors still investigate because the same symptom has other causes, and one of them is worth finding early. ACOG says endometrial hyperplasia, a womb lining that has grown too thick, usually shows up first as abnormal bleeding, including periods that are heavier or longer than usual and cycles shorter than 21 days. Hyperplasia is not cancer, but ACOG says some forms of it, including a precancerous type called endometrial intraepithelial neoplasia, can lead to cancer of the womb. That is the one worth finding early.

ACOG's risk factors for hyperplasia include age over 35, obesity, smoking, never having been pregnant, PCOS, diabetes, thyroid disease and a family history of ovarian, colon or uterine cancer. It also says that anyone 35 or older with abnormal bleeding may be offered tests for hyperplasia and cancer. That is routine at this age and does not mean the doctor expects to find either.

The other causes that ACOG and the NHS list are worth knowing too:

• fibroids and polyps, growths in the womb that are usually not cancer
• adenomyosis, where the lining grows into the muscle wall of the womb
• an underactive thyroid, which can stop ovulation in the same way perimenopause does
• medicines such as blood thinners and aspirin, hormonal contraception and the copper IUD
• bleeding disorders, more likely if your periods have been heavy since your teens
• pregnancy-related bleeding and pelvic infections

What happens at the appointment

ACOG says your doctor will ask about your health history, pregnancies, every medicine you take (including ones bought over the counter) and your contraception, and will usually do a physical and pelvic exam. Blood tests can check for anaemia and bleeding disorders, and you may have a pregnancy test and tests for sexually transmitted infections.

Depending on your age and symptoms, the next step is often a transvaginal ultrasound, which measures how thick the womb lining is. A thick lining can lead to an endometrial biopsy, a small sample of the lining looked at under a microscope, or a hysteroscopy, where a thin camera looks inside the womb. ACOG notes that a biopsy is the only way to tell for certain whether cancer is present, which is why a doctor may suggest one even when the scan looks reassuring.

There are medicines and procedures that shorten or lighten bleeding, and which one fits depends on the cause and your health history. That choice belongs with your doctor. We do not give treatment advice on Peri Signals.

What to write down while you are bleeding

ACOG suggests keeping track for several weeks before the visit: the dates, how long each bleed lasted and the type of flow. For bleeding that goes on and on, I would add a few details to each day:

• the flow word, and how many pads or tampons you used on the heaviest days
• the size of the largest clot, compared with a coin
• any day you felt dizzy, breathless or unusually tired, rated mild, moderate or severe
• any pain, and any new medicine or change of contraception

Our printable symptom diary and appointment checklist gives each day a space for flow, and a notes app works as long as each line carries the date. Put a one-line summary at the top: "bleeding since 3 October, 21 days so far, heavy on days 2 to 6, clots the size of a 10p".

My take

I would book an appointment once a bleed passes day 8 or runs clearly longer than your own normal, without waiting to see whether it reaches three weeks. The likeliest cause is a cycle without ovulation, and a doctor can confirm that quickly with a scan. If you are soaking a pad every hour and feel faint, I would go the same day. Bring the daily list, because "about two weeks, quite heavy" is much harder to act on than dates and flow words.

Related reading

Every guide to changing cycles is collected under periods and bleeding, and perimenopause symptoms and how to track them sets bleeding changes beside the other symptoms of the transition.