Types of vaginal bleeding

Menstruation or bleeding: what is the difference?

A period (menstruation) is the planned shedding of the womb lining at the end of a cycle. It follows a rhythm you can count from the first day of one bleed to the first day of the next. The American College of Obstetricians and Gynecologists (ACOG) puts a normal cycle at 24 to 38 days and a period at up to 8 days.

"Bleeding" is the wider word. Doctors use it for any blood from the vagina, and they sort it by when it comes, how much there is and how long it lasts. A bleed that turns up in the wrong place in your cycle, or that breaks the pattern your periods normally keep, is what the guidance calls abnormal uterine bleeding. That label describes a pattern. It is a reason to look for a cause, and on its own it says nothing about how serious that cause is.

Perimenopause blurs the line. ACOG says the days between periods may change, and that skipped periods and lighter or heavier bleeding are common in the years before menopause. A cycle that drifts from 28 to 23 days is still a period. Light bleeding ten days after the last one may be spotting, or an early short period, and only your dates can tell them apart.

The types of vaginal bleeding, one by one

Each type below links to the page on this site that covers it in full.

A period that has changed shape

Closer together, further apart, lighter, heavier, or a month skipped: in your 40s these are the commonest changes, and they are usually the first sign of perimenopause. ACOG still asks women to mention them, because the same pattern can hide something else. Our guide to irregular periods in perimenopause explains which shifts belong to the transition, and two periods in one month covers short cycles under 21 days.

Spotting between periods

Spotting means a few drops of pink, red or brown blood outside a period, often seen only on toilet paper or a liner. The NHS page on bleeding between periods or after sex says it is not usually serious and should always be checked. Hormonal contraception, polyps, fibroids and infections are its common causes. More in spotting between periods in perimenopause, and if you think you could be pregnant, implantation bleeding explains the timing.

Breakthrough bleeding on hormonal contraception

This is unplanned bleeding or spotting while you use the pill, patch, ring, implant, injection or hormonal coil. A clinical reference from Patient.info, based on Faculty of Sexual and Reproductive Healthcare guidance, says up to 20% of women on the combined pill get it, that missed pills are a common cause, and that it usually settles within three cycles of starting. Two things change the picture. Bleeding that starts after years of a quiet pattern on the same method deserves a closer look than bleeding in the first months. The same reference also suggests doctors consider checking the womb lining in women aged 45 or over with this kind of bleeding. Because contraception can also mask what your own cycle is doing, see perimenopause on hormonal contraception.

Bleeding after sex

The NHS names four usual causes: harmless changes on the surface of the cervix (cervical ectropion), polyps on the cervix, vaginal dryness and sexually transmitted infections. Dryness becomes more common as estrogen falls, which is covered in vaginal dryness and bladder changes in perimenopause. Bleeding after sex is on ACOG's not-normal list whatever your age, and it is worth mentioning even if your cervical screening is up to date.

Heavy bleeding

Heavy means more than a bad day. The NHS heavy periods page gives signs you can measure: changing a pad or tampon every one to two hours, using two at once, passing clots bigger than 2.5 cm, bleeding through clothes or bedding, or feeling tired or short of breath a lot. That last sign can point to iron deficiency anaemia. Our article on heavy periods and blood clots in perimenopause goes through the thresholds, and the PBAC blood loss scorer turns a period's pads and tampons into a number.

Prolonged bleeding

ACOG's patient FAQ on abnormal bleeding counts bleeding that lasts more than 7 days as abnormal. In perimenopause it often comes from months when no egg is released, so the lining builds up without the progesterone that would normally shed it on time. That same mix of estrogen with too little progesterone is linked to endometrial hyperplasia, a thickened lining, which is why doctors look into bleeding that goes on and on. See bleeding for weeks in perimenopause.

Bleeding after menopause

Once you have gone 12 months with no period, any bleeding counts, including one spot of pink or brown. The NHS page on postmenopausal bleeding says to see a GP even if it happened once or there was very little, and that you should not wait more than two weeks to see a specialist. The common causes are thinning of the vaginal lining, polyps and a thickened womb lining, and less often cancer. Bleeding after menopause has the details.

Bleeding but not on your period: what it could be

If you are bleeding and you are sure it is not your period, the causes the NHS and ACOG list fall into a few groups:

• Hormones: the swings of perimenopause, or hormonal contraception and the emergency pill
• Growths in or near the womb: polyps and fibroids, which are usually not cancer
• Infection: chlamydia and other sexually transmitted infections
• Pregnancy: early pregnancy bleeding, miscarriage or an ectopic pregnancy, all still possible in perimenopause (see can you get pregnant during perimenopause?)
• Dryness and the cervix: thin, dry vaginal tissue, or cervical ectropion
• Less often: endometrial hyperplasia, or cancer of the cervix or womb lining

Blood in your pee can look like vaginal bleeding too, and it needs its own urgent check. Colour on its own rarely settles anything: our guide to period blood colours explains what pink, red and brown usually mean.

When to worry about vaginal bleeding

The NHS and ACOG sort bleeding into three levels of urgency.

Get help now (999, A&E, or your local emergency number) if you are soaking through a pad or tampon every hour for more than two hours in a row and you also feel dizzy or lightheaded, have chest pain or are short of breath. ACOG treats that combination as an emergency.

Get an urgent GP appointment or call NHS 111 if you have recently missed a period and now have unusual bleeding with pain anywhere in your tummy. The NHS says this could be an ectopic pregnancy.

Book a routine GP or gynaecology appointment for bleeding between periods, bleeding after sex, periods that have become heavy or run past 7 days, cycles shorter than 21 days, and breakthrough bleeding that has not settled after three months on a method. Any bleeding after menopause belongs here too, with the NHS two-week specialist rule on top.

If you are unsure which group you are in, the perimenopause bleeding checker asks about timing, flow and other symptoms and gives you a level to act on.

What to bring to the appointment

ACOG suggests tracking your bleeding for several weeks before a visit: the dates, how long each bleed lasted, and whether it was spotting, light, medium or heavy. I would add whether it followed sex or a missed pill, any pain and where you felt it, and every hormone or blood-thinning medicine you take. The printable symptom diary has a row for each. For the tests a doctor may offer, from a blood count to an ultrasound, see how abnormal uterine bleeding is diagnosed.

My take

I'd judge any bleeding by one question first: does it fit the rhythm of my periods? If it does, even a period that has shifted by a week, I'd start with a note in the diary and mention it at the next appointment. If it doesn't, because it comes mid-cycle, after sex, after a year with no periods, or in amounts that soak a pad an hour, I'd book the appointment now and bring the dates. I would skip trying to read the cause from the colour or the amount alone. Perimenopause explains a lot of odd bleeding in your 40s, but only a doctor can confirm it.

Related reading

Every page on cycle changes is gathered under periods and bleeding. For the rest of the symptom picture, start with perimenopause symptoms and how to track them.