Written by: Dr. Amy Beckley, PhD, Founder and Inventor of the Proov test — the first and only FDA-cleared test to confirm successful ovulation at home.
You’re at the doctor’s office and they ask, “When was your last menstrual period?” Ummm...
For some women, that question is not straightforward due to other types of bleeding that are not true menstruation.
Didn’t know that bleeding may or may not be menstruation? No worries – you’re not alone. Here’s what you need to know to feel confident about the start date of your last menstrual period.
What’s the difference between spotting and a period?
This is the sticking point and why many women aren’t sure when their last menstrual bleed began. Short answer: Flow is the main difference between a menstrual period and spotting.
Menstruation has flow that can be described as light, moderate, heavy or even very heavy. It often follows a crescendo-decrescendo flow pattern, ie: light, moderate, heavy, moderate, light. Spotting does not have an intensity of flow.
Beyond flow, true menstruation occurs after ovulation if pregnancy did not occur. In other words, unless you know you ovulated in the previous cycle, the bleeding you’re experiencing may not be a menstrual period.
It’s very important to know if you ovulated in the previous cycle because it qualifies your bleeding as true menstruation.
Many women were taught that menstruation is the sloughing or shedding of the lining of the uterus. That’s correct but let’s complete the story.
How did the lining of the uterus come to build up, and then why did it shed? Here’s the full story.
Your cycle begins with the first day of menstrual bleeding. Most women bleed for 3-5 days but a menstrual bleed that is only two days or as long as seven days is still considered normal.
This bleeding happened because pregnancy did not occur and the uterus needs to get rid of the old lining so that a new one can be built up.
If we think of the lining of the uterus like the bedding for baby’s first bed, menstruation can be thought of as stripping the bed so that fresh new linens can make up a new bed.
For information on all 4 stages of your cycle including the menstrual phase, check out this blog.
What could the bleeding be if it’s not true menstruation?
There are 4 types of physiological bleeding that may occur at various stages of a woman’s reproductive life. All of these can manifest as spotting.
- Intermenstrual Bleeding
- Breakthrough Bleeding
- Withdrawal Bleeding
- Implantation Bleeding
Let’s unpack them one by one.
Intermenstrual Bleeding
This is bleeding that happens in between true menstrual bleeds. It may occur without ovulation in the previous cycle and is therefore not true menstruation.
It occurs because there was an estrogen rise from a developing follicle. This rising estrogen causes the lining of the uterus to thicken. The hormonal cause of intermenstrual bleeding can be either a rise or drop in estrogen.
If you have 2 or more cycles with intermenstrual bleeding, consult a knowledgeable women’s health physician who can help you learn the underlying cause.
Breakthrough Bleeding
If there is follicular development within the ovary, there will be a rise in estrogen. Rising estrogen from the follicle in the ovary tells the lining of the uterus to thicken.
If estrogen is high, bleeding occurs due to leaking from a thickened endometrium.
Withdrawal Bleeding
Hormonally the opposite of breakthrough bleeding, withdrawal bleeding happens when ovarian production of estrogen drops. Dropping estrogen leaves the lining of the uterus unsupported. An unsupported uterine lining will shed.
Menstruation can be thought of as a withdrawal bleed because it is caused by a drop off in estrogen. True menstruation, unlike an anovulatory withdrawal bleeding, is also due to a drop off in progesterone which is made by the empty follicle that luteinized into something called a corpus luteum.
Implantation Bleeding
Implantation bleeding occurs 10-14 days after conception during early pregnancy. After conception, there is rapid human development as the new life travels through the fallopian tube to the uterus.
After the journey down the tube, the new life that is now an embryo burrows into the thickened lining. This burrowing can cause some of the uterine lining to discharge out of the vagina as blood. Implantation bleeding is usually light to very light.
Important: If you are concerned with the frequency, heaviest, or any pain associated with any bleeding, please consult a women’s health physician.
How to Tell the Difference between Spotting and True Menstruation
As true menstruation comes after ovulation, confirmation of ovulation in the previous cycle would be the foolproof way to know if you are menstruating or experiencing a different type of bleeding. Ultrasound is the gold standard to confirm ovulation but, of course, we can’t do that every cycle.
In-home testing for a progesterone rise after suspected ovulation is a convenient way to determine if you ovulated prior to bleeding. Here’s how to test for progesterone at home.
Flow that is your menstrual bleed can be described in terms of color, amount of blood, intensity of flow, and menstruation-related symptoms.
Examples of color include: pink, red, dark red, copper, and brown.
Amount of blood loss in a normal menstrual bleed is about 2 to 3 tablespoons (30 to 45 milliliters). This can be determined by using menstrual cups instead of pads or tampons.
If you are concerned with the amount of blood loss during your cycle, please consult an ob-gyn. Here’s more information on heavy bleeding.
Intensity of flow can be described as follows: light, moderate, heavy, very heavy. As a point of reference, moderate flow means changing your pad or tampon about every 4 hours. Again, a menstrual period typically follows a crescendo-decrescendo flow pattern.
Symptoms that may be cycle-related are very important to note. Notably symptoms include:
- Pain of any kind (cramps, back pain, headaches)
- Clots larger than a quarter
- Mood changes
- Sleep changes
- Acne
- Facial hair or hair in the midline of your body
What if spotting occurs before my period?
Spotting is light bleeding that occurs outside of your menstrual period, before or after or completely separate from what you know to be menstrual flow. The underlying cause is often a premature drop off in a hormone called progesterone after ovulation.
Even more specifically, thinking of why progesterone would be low, spotting before your menstrual flow may be due to ovulatory dysfunction.
If premenstrual spotting happens for more than 2 consecutive cycles, please consult a knowledgeable ob-gyn who can help you get to the underlying cause.
Check out this full length article discussing spotting before your menstrual flow. It includes tips on lifestyle strategies like stress reduction, weight management, certain herbs, and seed cycling.
