Irregular periods at 45: is it menopause?

What do irregular periods at 45 look like?

In your 40s it is very common for periods to stop arriving like clockwork. According to the NHS, one of the first signs of perimenopause is usually a change in your periods: they may come more or less often, and bleeding may get lighter or heavier (NHS, Symptoms). The Menopause Society explains that cycles often get a little shorter at first, that as the transition goes on their length can vary by 7 days or more, and that in the later stage you may skip periods for 60 days or more (The Menopause Society, Perimenopause).

So having a period after 24 days one month and after 38 days the next, skipping a month entirely, or bleeding very little in one cycle and a lot in another are all patterns you may meet in these years.

Why does the cycle change before menopause?

The transition to menopause happens as the ovaries gradually work less. The STRAW+10 working group notes that in the late transition, cycle length becomes more variable, hormone levels swing widely, and cycles without ovulation become more frequent (Harlow et al., 2012). This variability is what you feel as your period coming sometimes early, sometimes late.

The Turkish Society of Obstetrics and Gynecology (TJOD) also notes that the transition can begin from the 40s onward with irregular bleeding, linked to less frequent ovulation, and with hot flashes (TJOD).

Which stage are you in? STRAW+10

The international STRAW+10 classification divides the transition into stages based on the pattern of your cycle (Harlow et al., 2012):

• Early menopausal transition: A persistent difference of 7 days or more between the lengths of consecutive cycles, meaning it happens again within 10 cycles after the first irregular one.
• Late menopausal transition: No period for 60 days or longer. This stage lasts 1–3 years on average, and hot flashes are common in it.
• Postmenopause: No period for 12 months after the last one. Your last period is only confirmed once these 12 months have passed.

These criteria are meant to be used regardless of age, ethnic background or body type (Harlow et al., 2012). You can see which stage your own cycle pattern looks like with a short quiz; the result is not a diagnosis.

Is this normal at 45?

Most of the time, yes. In Türkiye, the average age at menopause is 47–49 (HSGM; TJOD). The NICE guideline treats new hot flashes together with a change in the cycle, in otherwise healthy people aged 45 and over, as perimenopause without the need for a lab test. If someone who is not using hormonal contraception has had no period for at least 12 months, that is considered menopause (NICE NG23, 1.3.1). TJOD also says that one year without a period is enough to diagnose menopause (TJOD). NICE also reminds readers that menopause can happen at a younger age in some ethnic groups and with some long-term conditions (NICE NG23, 1.3.3). For the overall picture of perimenopause, see what is perimenopause.

Saying “normal” does not mean every bleed can be ignored. ACOG (the American College of Obstetricians and Gynecologists) stresses that changes in your periods as you approach menopause are ordinary, but that these changes should still be discussed with a gynecologist (ACOG, FAQ162).

Which kinds of bleeding are not a normal change?

According to ACOG, these kinds of bleeding are not considered ordinary (ACOG, FAQ162):

• Bleeding or spotting between periods.
• Bleeding or spotting after sex.
• Heavy bleeding during your period.
• Bleeding that is heavier or lasts longer than usual.
• Any bleeding after menopause.

The NHS also asks you to see your GP if your bleeding is getting heavier rather than lighter. Any bleeding more than 12 months after your last period should be checked, even if it is a one-off, a small amount, or a pink-brown discharge. This bleeding is usually not due to a serious cause, but it needs to be assessed because it can be a sign of cancer (NHS, Symptoms). NICE’s suspected cancer guideline recommends an urgent referral for endometrial cancer (cancer of the lining of the womb) in people aged 55 and over with unexplained bleeding after menopause (NICE NG12, 1.5.12). In Türkiye, the Ministry of Health’s Public Health Directorate (HSGM) also asks that irregular bleeding before and after menopause not be treated as ordinary, and that you always see a doctor (HSGM). Detailed information on bleeding after menopause is on the bleeding after menopause page.

What else can irregular periods be a sign of?

ACOG lists possible causes of abnormal bleeding including polyps (non-cancerous growths on the wall of the womb or the cervix), endometrial atrophy (thinning of the lining of the womb), endometrial hyperplasia (excessive thickening of the lining of the womb) and endometrial cancer (ACOG, FAQ162). Hyperplasia is not cancer, but in some cases it can lead to cancer; this is why finding the cause matters.

Beyond these, a few other situations should come to mind:

• Pregnancy: Pregnancy is possible in perimenopause even when cycles are irregular (The Menopause Society, Perimenopause).
• Hormonal methods: Hormonal contraception, or hormonal treatments used for heavy periods, change your period pattern and so make the transition harder to notice (NHS, Symptoms; NICE NG23, 1.3.2).
• Before 40: Periods becoming less frequent or stopping at this age are handled separately in the NICE guideline. The assessment is based on symptoms and on FSH levels in two blood samples taken 4–6 weeks apart; a decision is not made from a single blood test (NICE NG23, 1.7.2–1.7.3).

What can you record yourself?

Most of the questions your clinician will ask can be answered with a few simple records:

• The day each period starts and ends.
• How heavy the bleeding is: how many pads or tampons you change a day, and whether there are clots.
• Spotting days outside your period, and bleeding after sex.
• The number of days between periods.
• Symptoms that come along with it, such as hot flashes and night sweats.

Keeping the record for at least a few cycles stops a single month from being misleading. STRAW+10 also looks not at a single irregular cycle but at a difference that recurs within 10 cycles (Harlow et al., 2012).

The Menopause Society suggests tracking changes in bleeding in a calendar or a phone app and discussing them with a health professional (The Menopause Society, Perimenopause).

What to expect at the doctor’s, and what to ask

Your clinician will first look at your history and your records and examine you. ACOG mentions tests used to look for the cause of abnormal bleeding, such as a pelvic ultrasound, taking a sample from the lining of the womb (biopsy), or a special ultrasound in which fluid is put into the womb (sonohysterography) (ACOG, FAQ162). Your clinician decides which one is needed.

At the appointment you could ask:

• Is this pattern consistent with perimenopause, or do we need to look for another cause?
• With which change in bleeding should I call you without waiting?
• If a test is needed, which one, and why?
• Which stage does the pattern in my records fit best?
• Until when should I keep using contraception?

This page does not recommend any medication or treatment; talk through your options with your clinician.