A typical menstrual cycle involves a regular pattern of increases and decreases in estrogen and progesterone levels and the release of an egg (ovulation) in the middle of the cycle. After years of experiencing menstrual bleeding, most women have a pretty good idea of what to expect each month in terms of intensity of cramping, length of time they bleed, type of blood flow, and what they can do to relieve their symptoms. As women approach and enter perimenopause and then menopause, however, things change. Among those changes may be abnormal bleeding and phantom periods.

Abnormal bleeding in perimenopause and menopause

When women reach their late thirties to early forties, changes begin to occur in hormone levels and ovulation. The perimenopausal phase can be as short as a few months but usually can last 10 years or more. Estrogen levels begin to decline and the ovaries may or may not release an egg each month. This can result in uncertainty and anxiety over whether—or when—bleeding may occur. Periods also may become longer or shorter than you are used to, and the amount of bleeding may change as well. The number of days between periods may increase or decrease, and some months you may not bleed at all.

Read about menopause and shorter periods

While uncertainty about your period and bleeding is not unusual in perimenopause, once you have reached menopause and postmenopause, the occurrence of any postmenopausal bleeding should be evaluated by a physician. This includes any spotting or reddish or brown discharge, even if it occurs only once and you don’t experience any other symptoms.

Among the more common causes of postmenopausal bleeding are:

• Atrophic vaginitis, which involves inflammation, drying, and thinning of the lining of the vagina associated with low estrogen levels. These signs and symptoms can lead to spotting or bleeding.
• Endometrial atrophy, which also involves inflammation and thinning of the womb (uterus) associated with low estrogen. Thinning of the uterine lining can result in spotting or bleeding.
• Endometrial hyperplasia (thickening of the womb lining), which can be caused by taking hormone replacement therapy, being overweight, or high estrogen levels.
• Cervical or womb polyps, which are growths (usually noncancerous) that develop on the cervix or womb. About two-thirds of women with polyps don’t experience any symptoms, but they may include abnormal bleeding

Even though postmenopausal bleeding is usually not cause for great concern, in some cases it can be a sign of ovarian or womb/endometrial cancer. Therefore, see your doctor if you notice any spotting or bleeding postmenopause.

What is period pain?

Period pain is the discomfort and pain (i.e., abdominal and/or pelvic cramping) women experience around their menstrual cycle because the muscle layer in the uterus contracts in an effort to expel menstrual blood and clots. If you are a heavy bleeder, then your contractions may be more forceful, although some women report mild period pain with a heavy flow while others are light bleeders and experience gut-wrenching cramps. Cramps serve a beneficial purpose (although you may not feel like they do) of clearing out the uterus to prepare it for new tissue for your next cycle.

But there is also period pain without bleeding. This is common among women in perimenopause because estrogen, progesterone, follicle stimulating hormone, and prostaglandin levels rise and fall erratically. The result can be no menstrual bleeding and irregular periods but the occurrence of other symptoms, including uterine cramping (period pain), tender breasts, and bloating.

Read more about perimenopause: what women should know

Phantom period pain

This uterine cramping without bleeding is sometimes referred to as phantom period pain or ghost period pain. In addition perimenopause, phantom period pain can occur for many different reasons, which we talk about here. If you ever experience phantom period pain and are concerned or uncertain about the cause, see your doctor.

• Birth control. Women who use hormonal birth control frequently experience spotting, skipped periods, or a very light flow. Accompanying these episodes are often abdominal cramping and tender breasts. If you are using birth control pills or hormonal IUDs as you enter perimenopause, phantom period pain may become more frequent.
• Endometriosis. This inflammatory condition involves the growth of uterine tissue outside of the organ, usually in the pelvic region. Women who have endometriosis may experience phantom period pain at any time, although it usually occurs earlier than typical PMS cramping and can last beyond one’s period. The severity of symptoms can vary widely.
• No ovulation. Referred to as anovulation, this is when the body experiences symptoms typically associated with hormonal changes and PMS but no egg is released. If you are in perimenopause, anovulation is normal, especially as you get closer to menopause. Other reasons for anovulation include very low body weight or the presence of polycystic ovarian syndrome (PCOS).
• Pelvic floor muscle issues. You may be familiar with the pelvic floor muscles because they are involved when doing Kegel exercises. This group of muscles is involved in supporting the bladder, rectum, uterus, vagina, and other pelvic organs. Pelvic floor muscles can become weak or damaged by pregnancy, childbirth, or surgery in that region of the body and cause symptoms such as phantom period pain or pressure. Practicing Kegel exercises may provide some relief from phantom period pain. A pelvic floor physiotherapist can also be very helpful.
• Thyroid issues. The thyroid gland has many roles, and one of them is regulating your menstrual cycle. If your thyroid gland is not functioning properly, you may experience menstrual-type cramping. Since various thyroid conditions are more common in women than in men (e.g., hypothyroidism, Grave’s disease, Hashimoto’s thyroiditis) and is more prevalent among older women, phantom period pain may be related to a thyroid issue and should be checked by a physician.
• Stress. When you experience stress or anxiety, your cortisol levels rise and impact your hormone balance. These factors can result in phantom period pain.
• Uterine polyps. These noncancerous growths can develop in the uterine wall and cause abdominal cramping and discomfort as your body tries to expel them, which triggers uterine contractions. Because there is a small risk of uterine cancer developing from these polyps, your doctor may recommend removing them, which can be accomplished with a procedure called a hysteroscopy. This involves threading a tube through the vagina into the uterus to view and remove the polyps. 
• Polycystic ovary syndrome (PCOS). This condition is caused by having too many androgens, which in turn impact ovary function and can result in irregular periods and period pain, weight gain, and insensitivity to insulin. PCOS affects up to 20 percent of women around the world, and as women get older and enter menopause, experts have noted that it is “a major risk factor for the development of type 2 diabetes and cardiovascular disease.”
• Ovarian cysts. Although the ovaries produce several cysts every month, only one releases an egg. Typically the remaining cysts go away quickly and don’t cause any problems, but if any do not, they may trigger phantom period pain. 
• Pelvic inflammatory disease (PID). Although PID is typically more common among women younger than 45, the prevalence in postmenopausal women has been shown to be 11.5 percent. This condition involves infection of the ovaries, uterus, or fallopian tubes and is usually caused by sexually transmitted bacteria. A common symptom of PID is cramping, so if you are experiencing this phantom period pain and have had a new sex partner, you may want to be checked for sexually transmitted infections.
• Urinary tract infections. If you have ever had a urinary tract infection (UTI), you may have experienced pelvic cramping. An untreated UTI can lead to something more serious, including a potentially lethal kidney infections, so it’s best to seek medical help if you are experiencing other symptoms along with the phantom period pain, such as burning and pain when urinating and needing to urinate often.
• Interstitial cystitis. This is a painful condition in which the bladder wall is inflamed and causes stiffening and scarring and thus an inability to hold much urine. One of the most common symptoms is pelvic pain, an urgent need to urinate often, and pain during intercourse. Although the exact causes are not known, some possibilities include an autoimmune reaction, allergy, infection, or an abnormality in the bladder lining.
• Irritable bowel syndrome. One of the most common symptoms of irritable bowel syndrome is persistent abdominal discomfort or pain. This intestinal disorder, which involves diarrhea, constipation, or both, affects more women than men, so women who may be experiencing the changing bowel habits along with the phantom period pain should see a physician for an evaluation.
• Ovarian cancer. Most cases of this relatively rare type of cancer occur in postmenopause. Symptoms of ovarian cancer, which are often mild or nonexistent, can include phantom period pain, urinary problems, abdominal bloating, and weight loss.
• Inflammatory bowel disease (IBD) is a chronic autoimmune condition that includes ulcerative colitis and Crohn’s disease. The cramping and lower region pain that accompanies IBD can feel like period pain. If you are experiencing other symptoms such as fecal incontinence or urgency, diarrhea, weight loss, or fever, see your physician as soon as possible.
• Lactose intolerance. Many people have an inability to properly digest foods that contain a sugar called lactose, which is found in milk and milk products. One of the most common symptoms is abdominal cramping and bloating similar to getting your period. If you experience this type of pain frequently, keep a food diary so you can see if there is a relationship between what you are eating and the appearance of the pain.
• Indigestion. Is it indigestion or phantom period pain? If you begin to feel the cramping while eating or shortly thereafter, it may be the former, especially if you are also experiencing burning, bloating, nausea, and uncomfortable fullness during or immediately after eating.
• Decidual cast. This is a very rare condition in which the entire lining of the uterus sheds at once instead of over a few days, as it normally does during a woman’s period. A decidual cast may occur if progesterone levels are elevated and the uterine lining develops into a mass of tissue that becomes more difficult to release. That’s when the contractions become intense and causes phantom period pain. Eventually, however, the uterine lining will be expelled. Decidual casts are most common among women who use oral contraceptives that contain progesterones.

Bottom line

Unusual or atypical bleeding during perimenopause is common as your hormones undergo significant fluctuations and your body attempts to adjust to the changes. When such bleeding occurs in postmenopause, you should seek medical help. Phantom period pain also is common in perimenopause, and it can also appear postmenopause and be associated with a wide variety of factors and conditions. Whenever in doubt or you are concerned about any of these signs and symptoms, consult your healthcare provider.