Hormonal health
Not all changes are perimenopause. Here is when to seek urgent medical evaluation.
While a gradually lengthening cycle is often a normal part of perimenopause, certain patterns of change indicate something that requires prompt medical assessment. The American College of Obstetricians and Gynecologists (ACOG) describes perimenopause as a 'diagnosis of exclusion' — meaning other conditions must be ruled out before attributing changes to the hormonal transition.
SEEK MEDICAL ATTENTION IF YOU EXPERIENCE ANY OF THE FOLLOWING
Heavy bleeding soaking a pad or tampon every hour for 2+ consecutive hours · Periods lasting longer than 7 days · Bleeding between periods or after sex · Any bleeding more than 12 months after your last period (postmenopausal bleeding) · Sudden onset of extremely irregular cycles with no prior history · Severe pelvic pain accompanying your periods · Cycle changes accompanied by unexplained weight loss, extreme fatigue, or other systemic symptoms.
Conditions that must be ruled out
Condition | How it presents | Diagnostic tool |
|---|---|---|
Endometrial hyperplasia | Irregular, heavy, or prolonged bleeding — especially with oestrogen exposure without progesterone opposition | Endometrial biopsy, ultrasound |
Endometrial cancer | Postmenopausal bleeding; irregular bleeding with risk factors (obesity, diabetes, late menopause, HRT) | Endometrial biopsy, hysteroscopy |
Cervical pathology | Bleeding after sex, between periods, or after examination. May be subtle. | Cervical smear, colposcopy |
Ovarian cysts | Irregular cycles, pelvic pain or pressure, bloating. Many are asymptomatic. | Transvaginal ultrasound |
Bleeding disorders | Heavy menstrual bleeding since adolescence; easy bruising; prolonged bleeding after cuts or dental work. | Coagulation blood panel (von Willebrand screen) |
Pelvic inflammatory disease | Irregular bleeding, pelvic pain, unusual discharge, fever. Often follows untreated STI. | Swabs, blood tests, pelvic exam |
The PALM-COEIN classification
Clinicians use the PALM-COEIN system (endorsed by the International Federation of Obstetrics and Gynecology, FIGO) to categorise abnormal uterine bleeding. Structural causes (Polyp, Adenomyosis, Leiomyoma/fibroid, Malignancy) are investigated with imaging and biopsy. Non- structural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified) are investigated with blood tests and history. Perimenopause falls under 'Ovulatory dysfunction' — but this is only assigned after structural causes are excluded.
Read more: Period problems & abnormal bleeding — U.S. Office on Women's Health ↗
