Spotting is light, unexpected vaginal bleeding, often appearing as a few drops or a stain. Whether spotting is normal depends entirely on the phase of the menopausal transition. It can be frequent and expected during the years leading up to the final menstrual period, but it is never normal after that period has officially concluded. Understanding the specific stage is paramount to determining the significance of any unexpected bleeding.
Distinguishing Perimenopause and Postmenopause
The menopausal transition is divided into two main stages. Perimenopause, meaning “around menopause,” is the years-long phase leading up to the final period, often beginning in a person’s 40s. During perimenopause, the ovaries gradually slow down and hormone levels become erratic, causing irregular menstrual cycles. Postmenopause is a definitive biological state that begins after a person has gone 12 consecutive months without a menstrual period. This 12-month mark is the clinical definition of menopause itself, and any bleeding after this point is termed postmenopausal bleeding (PMB).
Causes of Spotting During the Menopausal Transition
Spotting during perimenopause is linked to shifts in reproductive hormones. The ovaries produce estrogen and progesterone unevenly, directly affecting the stability of the uterine lining, or endometrium. This hormonal imbalance can cause irregular or incomplete shedding of the lining, resulting in unexpected light bleeding between periods.
Changing hormone levels also contribute to the development of polyps, which are growths that can form in the cervix or uterus. These polyps are often fragile and bleed easily, sometimes triggered by intercourse or a physical exam. Spotting can also be a common side effect of hormonal medications, such as low-dose birth control, used to manage perimenopausal symptoms, especially when starting a new regimen.
Identifying Spotting That Requires Medical Attention
Any vaginal bleeding, even light spotting, that occurs after the 12-month postmenopausal milestone is considered abnormal and must be evaluated by a healthcare provider. While most postmenopausal bleeding (PMB) cases are traced to benign causes, the possibility of a more serious condition necessitates investigation. The most common cause of PMB is endometrial atrophy, accounting for about 60% of cases.
Endometrial atrophy occurs when prolonged low estrogen levels cause the uterine lining to thin and become fragile, making it prone to easy breakdown and bleeding. Conversely, excess estrogen, sometimes from hormone replacement therapy or other medical conditions, can lead to endometrial hyperplasia, a thickening of the uterine lining. Hyperplasia is significant because it can contain abnormal cells that may progress to endometrial cancer, which is the most concerning, although least common, cause of PMB. Spotting is the most frequent symptom in over 90% of individuals diagnosed with endometrial cancer.
What to Expect During a Medical Evaluation
An evaluation for abnormal spotting typically begins with a detailed review of the patient’s medical history and a physical examination, including a pelvic exam. The initial diagnostic step often involves a transvaginal ultrasound, which uses sound waves to measure the thickness of the endometrium. An endometrial thickness of 4 millimeters or less in a postmenopausal person generally indicates a very low likelihood of cancer or hyperplasia and can often provide reassurance.
If the ultrasound shows a thickened lining or if the bleeding persists, the next step is usually an endometrial biopsy. This office-based procedure involves inserting a thin tube through the cervix to collect a small sample of the uterine lining for laboratory analysis. A hysteroscopy, which is a procedure where a thin, lighted scope is inserted into the uterus, may also be performed, often allowing the healthcare provider to visually inspect the uterine cavity and remove any polyps or targeted tissue samples.