Finding blood stains in your underwear can be frustrating. The sight may also come as a shock if you’re not expecting your period. When you spot — bleed outside of your menstrual cycle — you usually won’t see enough blood to make you reach for a pad or tampon. But spotting may leave you confused about what’s going on with your body, especially if you’re in perimenopause.

The transition from your fertile years to menopause — called perimenopause — can lead to many uncomfortable symptoms like hot flashes, sleep problems, vaginal dryness, and mood swings. Irregular menstrual bleeding, such as spotting, often occurs alongside these common symptoms of perimenopause.

Below we discuss spotting during perimenopause, including why it can happen and when you should talk to your doctor.

How Perimenopause Can Cause Spotting

During perimenopause, the ovaries don’t release eggs as regularly anymore, so ovulation gets skipped sometimes. When ovulation is skipped, the body does not make much progesterone that month, and this disrupts the body’s balance of estrogen and progesterone. These two hormones play important roles in your menstrual cycle — triggering the start of your period when their levels fall.

During perimenopause, hormone levels are unstable, sometimes increasing and decreasing daily. These constant changes mean that your reproductive system doesn’t always receive a clear message that it’s time to menstruate. This can lead your body to shed its uterine lining when it’s not supposed to or retain some of the tissue it would normally shed. Both of these situations can cause you to spot and bleed irregularly.

According to the American College of Obstetricians and Gynecologists (ACOG), menstrual bleeding may be lighter or heavier in perimenopause than what you’re used to. Hormonal fluctuations can lead to spotting in place of regular menstrual bleeding, especially early in the menopause transition. Later on, spotting or other irregular bleeding may follow a missed period.

Several women surveyed by ThisIsMenopause shared that they experience spotting: “I have irregular periods with persistent spotting between.” Another woman wrote, “I think I’m starting to not have a period, only light spotting occasionally now. I haven’t had a real [period] for two months.”

Spotting and unpredictable periods can be very frustrating. “[I] never know when, or if, I’m going to have a period,” a woman shared.

What Spotting Is Considered Normal

In general, spotting tends to involve less blood than a regular period. But this doesn’t mean that it’s impossible to mistake spotting for a period. Although some may see only small amounts of blood in their discharge, others may have spotting that feels heavier and similar to a period.

Before the start of perimenopause, spotting can happen for reasons that aren’t cause for concern. In younger women, spotting blood often appears pink or light brown and won’t last for more than two days. But there’s more variation in perimenopause.

Perimenopausal spotting can last up to several days. Although spotting can be due to perimenopause, it’s important to check in with your healthcare provider about it. Frequent spotting or heavy bleeding between periods, in particular, should be evaluated by a women’s health provider, such as an OB-GYN.

No amount of spotting is normal if you’ve reached menopause. Any postmenopausal bleeding — or bleeding after you’ve been without a period for at least one year — should be checked by a doctor.

Other Possible Causes of Spotting

Hormonal changes aren’t the only reason you may experience spotting. There are also medical conditions that can lead to irregular perimenopausal bleeding, such as:

• Endometrial cancer — Cancer of the endometrium (uterine lining) can often cause irregular bleeding prior to other symptoms.
• Endometrial hyperplasia — This thickening of the endometrium can often precede cancer.
• Endometriosis — This growth of uterine tissue beyond the uterus can also cause painful cramping during periods, pain during sex, and pelvic pain.
• Other gynecologic cancers — Cervical, ovarian, uterine, vaginal, and vulvar cancers are less common causes of spotting.
• Hypothyroidism — Low levels of thyroid hormones can impact bodily processes, such as menstruation, leading to spotting.
• Polycystic ovary syndrome (PCOS) — PCOS can lead to hormonal imbalances, cysts, and irregular bleeding.
• Pregnancy — Mild bleeding, especially in the first trimester, may occur after sex or a pelvic exam.
• Sexually transmitted infections (STIs) — Chlamydia and other STIs can sometimes cause spotting.
• Uterine fibroids and polyps — Benign growths within the uterus can also cause long periods, heavy bleeding, pelvic pain, and a frequent urge to pee.
• Vaginal dryness — Thinning of the vaginal tissue caused by low estrogen levels can lead to irritation and tiny tears that can bleed.

Hormonal birth control, such as oral contraceptives and intrauterine devices (IUDs), can also cause spotting, especially the first few months you’re using them. Menopause hormone therapy — a treatment prescribed for perimenopause symptoms — commonly causes bleeding during the first six months. Talk to your doctor about whether bleeding is a normal side effect.

When To Talk to Your Doctor

If you notice any spotting during perimenopause, it’s a good idea to make an appointment with your doctor. Although changes in hormones can cause unusual bleeding, certain bleeding patterns should be evaluated. For example, you should see a doctor if you have your period three or more times per month for several months in a row or if your bleeding stops and starts in a recurring pattern.

An evaluation is especially important if you’re experiencing heavy spotting or spotting along with other symptoms like pain. Certain symptoms may signal an underlying condition like endometrial cancer. See a healthcare provider promptly if you’re having symptoms, such as:

• Vaginal bleeding with lower abdominal pain
• Spotting or bleeding that appears out of the blue
• Vaginal discharge that has a foul or otherwise strong odor

Spotting can be a normal part of perimenopause. But it’s still important to rule out other possible causes of bleeding. Hormone changes during this time can raise your risk of developing other conditions like uterine polyps. So it’s a good idea to see your doctor and get checked out.

Managing Spotting During Perimenopause

The best way to manage spotting depends on its cause. To identify the cause of spotting during perimenopause, your doctor may ask about your family history and perform a pelvic exam. You may need more testing, such as a biopsy or ultrasound.

Depending on why you’re spotting, your provider may suggest different options to help manage irregular bleeding. Certain lifestyle changes, such as avoiding processed foods, getting daily exercise, and managing weight, may help to reduce spotting. Your doctor may also prescribe hormone therapies. These therapies are often used to manage spotting that occurs along with other hormonal symptoms like hot flashes.