After age 40, periods often become heavier and less predictable as hormones shift toward menopause. This is commonly due to perimenopause, but heavier bleeding and clots can also signal anemia, fibroids or polyps, thyroid problems, or medication/device effects. Track changes and see a clinician if bleeding is very heavy or symptoms worsen.

What’s Going On?

• Perimenopause: Fluctuating estrogen and lower progesterone can thicken the uterine lining, so when it sheds you may have heavier flow and visible clots.  

• Other causes: Uterine growths (fibroids, polyps), adenomyosis, thyroid disease, bleeding disorders, copper IUDs, or blood-thinning medicines can cause heavier bleeding.  

• Pregnancy (including early miscarriage) is still possible — test if relevant.

When clots are usually okay — and when they’re not

• Small, occasional jelly-like clots on heavy days are often normal.  
• Get evaluated if you regularly pass clots larger than about 1–2 inches, soak a pad or tampon every hour for 1–2+ hours, bleed longer than 7 days, or feel dizzy or faint (signs of possible anemia).

What simple steps to take now

• Track two cycles: flow, how often you change pads/tampons, clot size, pain, and any meds or missed contraception.  
• Take a pregnancy test if there’s any chance.  
• If you feel unusually tired or short of breath, ask your clinician to check iron (CBC and ferritin). Meanwhile eat iron-rich foods and pair them with vitamin C to boost absorption.

The Work Up

Expect questions about your cycles, a pelvic exam, and targeted tests — bloodwork for anemia and thyroid function, and an ultrasound to look for fibroids or polyps. Don’t accept “just perimenopause” without a basic workup.

Treatment options 

• Conservative: NSAIDs for pain and bleeding, iron supplements, lifestyle support.  
• Hormonal: Hormonal IUDs, combined birth control, or progestin therapy to reduce bleeding.  
• Non-hormonal: Tranexamic acid can significantly cut menstrual blood loss for many people.  
• Procedures: Polyp or fibroid removal, endometrial ablation (if you don’t want future pregnancy), or hysterectomy for severe, persistent cases.

When To Worry

Go to the ER or urgent care if you:

• Soak a pad/tampon every hour for 2+ hours  
• Pass repeatedly very large clots (golf-ball size)  
• Faint, have severe dizziness, or a racing heart  
• Have severe one-sided pelvic pain, fever, or foul-smelling discharge  
• Bleed after being 12 months without a period

Heavier, clotty periods after 40 are often from perimenopausal hormone changes and can be treated. But repeated heavy bleeding, large clots, or signs of anemia deserve prompt medical evaluation to find the cause and the right treatment.