127. Spotting Before Your Period: What it Means & What to Do

That brown or pink spotting before your period might be “no big deal”… or it might be a helpful clue. In this episode of Cycle Wisdom, Dr. Monica Minjeur explains how to tell the difference between harmless, occasional spotting and patterns that point to luteal phase deficiency, ovulation quality issues, or a uterine environment concern like chronic endometritis, plus how thyroid and insulin resistance can quietly contribute.

You’ll hear Chloe’s story—how cycle charting revealed spotting starting 9 days after ovulation, labs confirmed low progesterone, and cycle-timed progesterone support resolved the spotting and lengthened her luteal phase. Dr. Minjeur walks through exactly what to track, which labs to time (and when), when ultrasound or pelvic exam matters, and what treatment looks like when the cause is hormonal vs structural vs inflammatory.

Want a clear plan for your specific pattern? Book a free discovery call at radiantclinic.com (click Book Free Discovery Call) to learn how our restorative, cycle-informed approach supports hormone balance, cycle clarity, and fertility—through in-person care in Cedar Rapids, Iowa or telehealth across many states.

Transcript

Speaker: 0:02

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. What if that little bit of brown or pink spotting that you saw before your period actually started? Isn't just how your body works, but it was your body asking for attention. Today we're going to decode, premenstrual spotting, how to tell when it's normal, when it can point to luteal phase issues or a uterine environment concern like chronic endometritis and the exact cycle time steps to get answers without panicking. So let's start off with talking about a patient of mine who we'll call Chloe. Now, Chloe came to see us at about 30 years old, and she and her husband had been trying to conceive for the past six months. As we gathered her history, one of the big things that Chloe told me she was concerned about was the spotting that led up to the actual start of her menstrual cycle. Beginning she told me every month feels like it's a false start, and I don't know if it's actually going to turn into a full period or not. Those couple days of bleeding and brown discharge that Chloe had was ramping up her anxiety, and she had been told in the past that this is normal and this can just be what the start of a period looks like. After some more charting with us, she started to notice patterns, things like that. Her fertile signs look to be okay. She was ovulating consistently, but that her luteal phase was quite short. In fact, her spotting began about nine days after her ovulation day, which is earlier than expected. So what did we do for next steps? Chloe and I worked together to review her chart to talk about what was happening and specifically when and how much she noticed of that brown spotting that was starting before her cycle began. We timed labs to her cycle. Again, specifically looking at that progesterone and estrogen levels about seven days after ovulation, and found that in Chloe's case, her progesterone was quite low, which is a very common sign that we see with that premenstrual spotting. She had normal thyroid, she had normal blood counts, but she did have mildly elevated fasting insulin. On exam, there was nothing concerning her ultrasound looked to be normal, and since these symptoms continued, we did discuss the possibility of chronic endometritis. By the third cycle though, after treating with the progesterone, her premenstrual spotting was actually completely gone, and this eliminated the issue altogether. Chloe's luteal phase lengthened back out to about 14 or 15 days, and we were able to decrease her anxiety so that she had a more clear picture of what was going on. So why does pre period spotting happen and why does it even matter? Again, many women are told that this is completely normal. It doesn't create any issues, and while some cases of brown spotting or bleeding can be completely normal, I want to talk through today where are times that we need to be concerned and what we would recommend for evaluation. So if you are noticing brown blood, this can be very normal. Brown means it is oxidized blood, meaning there's been some oxygenated tissue that's with it. It's typically older blood that's moving more slowly, specifically through the cervix or in the endometrium, which is the lining of the uterine wall itself. If you have a small amount of this, it typically is not problematic. However, if you are persistently having multiple days of brown bleeding, again, specifically leading up to your cycle or towards the end of your cycle, this can signal issues with either hormones, anatomy issues or infections, timing or problems with the tissue itself. So let's talk about some of the main reasons why people have this premenstrual spotting. Okay. As we noted with Chloe, the most common reason for this is luteal phase insufficiency. So this is going to mean that there is not enough progesterone that happens after ovulation. In some individuals, this may mean that there is excessive estrogen and we just don't have enough progesterone to keep up with it. And in others, it just means that the progesterone is low in the first place. This causes early breakdown of that endometrial lining or of the uterine tissue, which can then show up as that brown spotting or the early spotting before an actual cycle begins. Another common reason we find that can cause issues is chronic endometritis. Now, I talked more in depth about this in episode one 13, so if you want to know more about it, you can go back and listen to that episode. But basically, chronic endometritis can be caused either from a uterine microbiome imbalance, so too much bacteria or yeast. Door, not enough of the right kinds of bacteria, and it can oftentimes cause micro polyps or small projections on the surface of the endometrium, which leads to other issues. Things like inflammation, increased blood vessels that are bursting, and all of these can cause some unusual bleeding. We also think about other anatomic causes, so things like fibroids or polyps, which are benign but can increase bleeding, may be a part of the picture here when we talk about irregular bleeding patterns. Another anatomic cause can be a cervical ectropion. And basically what this is, it's just inflammation of the cervix itself. This can be a completely normal variant that we see, and it's just that the surface of the cervix has more glandular tissue, which can sometimes be more irritated. If you have more problems with bleeding after intercourse, or if you're noticing significant problems with ongoing or persistent mucus discharge and there is no other infection present, cervical ectropion is something that is worth getting evaluated. Another reason that we can have problems with that premenstrual spotting would be insulin resistance or other metabolic or thyroid factors. Again, as you've heard me say so many times, insulin resistance and thyroid dysfunction can hijack everything else leading to impaired ovulation. And when ovulation is impaired, oftentimes the progesterone levels are going to be much lower. So all of this comes back to, again, figuring out why, why is the bleeding there in the first place? And that can help us to determine what we wanna do about it. Now specifically for people that are trying to conceive, if you're noticing this bleeding ahead of time, it can make a big difference from the standpoint of knowing when does implantation occur? If you have a short luteal phase before you start bleeding and before the lining of that uterus starts to slough off in order to have a menstrual period. It can actually impair implantation from occurring whatsoever. A fertilized egg requires a healthy uterine environment in order to be able to implant, and if it's already starting to bleed or if it is infected or inflamed with endometritis or doesn't have enough progesterone to support implantation, we can have significant issues with fertilization leading to that implementation. And if you are someone like Chloe who got incredibly stressed out when she had that recurrent spot in creating anxiety, it was dysregulating her cortisol, which impairs sleep, which further adds to this ovulatory and low progesterone dysregulation. So what does evaluation look like? As we discussed with Chloe, first thing is always going to be evaluating that charting. We want to have, be able to confirm when is the day of ovulation, ideally with cervical mucus, and utilizing other methods as appropriate. We want to record the exact onset duration, color, consistency of that bleeding. So it's not enough for me just to know today. I bled yes or no. I want to know what days were brown. What was the heaviness of that? Did you actually require an actual menstrual product in order to take care of the bleeding you noticed? Or was it just on the tissue when you wiped after going to the bathroom? Once we have this charting, it gives us a clear roadmap as to when we need to do your labs with your cycle. So again, as with many of our evaluations, we generally are checking labs about seven days after ovulation. Now, for some women, they don't have a very long luteal phase, and if they've already started spotting or bleeding by the time that the seven days after ovulation rolls around, sometimes we'll do it a bit earlier, four or five days after ovulation in some cases. Again, always checking along with the progesterone and estradiol level. We also want to check a full thyroid panel as well as thyroid antibodies if someone is having excessive bleeding, and we're always going to be looking for blood counts. Iron stores to make sure that they have enough to keep up with that increased bleeding that they're noting, and also to make sure that we're checking that fasting insulin or sometimes the full oral glucose tolerance test with insulin resistance in order to discern if there are other things that may be causing the ovulation defect. Again, you can have problems with low progesterone, but the next question is always why. So if we have low progesterone, is it that we're not producing enough? The ovulation quality is not enough. The follicle itself is not large enough. Always digging deeper to understand if you are told that your progesterone is low. Why? We also will always want to evaluate or consider evaluation for anatomic concerns. So again, pelvic exam allows us to take a look at that cervix to see is there any sort of inflammation, is there cervical ectropion? Is there any sort of infection that might be playing a role? If you have not already had one done recently, we also would always want to update an ultrasound. Ideally checking somewhere in the middle part of your cycle around the time of ovulation or afterwards so we can assess the thickness of the uterine wall lining and to rule out any polyps, fibroids, or other things that may be adding to that bleeding. And finally, again, as we've discussed in the past regarding chronic endometritis, we may consider doing menstrual sample blood to evaluate for the uterine microbiome or an endometrial biopsy in order to evaluate if that brown spotting continues. Now again, even though endometritis can cause brown bleeding. It's generally more common that we will pick that up at the end of a menstrual cycle, not just leading into a menstrual cycle. So again, more commonly, again, this is why we look at all these patterns. More common to have when you have premenstrual spotting or brown bleeding before a full period starts, almost always it's going to be a progesterone issue. Sometimes there's other anatomic issues, whereas if you're noticing more of that brown bleeding at the end of your menstrual cycle. More often we're thinking about chronic endometritis at that time, or some other anatomic variant because again, at that time of your cycle, progesterone levels should be near zero, so not the issue. So all the difference as to when that brown bleeding is happening. Timing, evaluation and looking at the patterns over time. So what does treatment look like? Again, we will pair treatment according to what the issue is. So again, as I mentioned, in most cases that premenstrual spotting or bleeding or brown bleeding is going to be from a luteal phase defect. So that generally just means my luteal phase is too short from the time that I ovulate until my next period starts. That's the luteal phase. So most commonly we're going to talk about bioidentical progesterone, and ideally we're giving this after ovulation has occurred. So usually in our practice, we start it three days after ovulation. We give it for 10 days each cycle. We also are always going to talk about what are the lifestyle changes that we can make to improve better production of progesterone, whether that's improving sleep quality, working on exercise, dietary choices, how are we dealing with excess stress in our lives? And most importantly, making sure that if there is something else that is causing the low progesterone, again, an ovulation defect or something like that, that we are correcting that underlying cause. If we find that there is something going on with the uterine environment, a chronic endometritis, for example, targeted antibiotics are generally recommended along with probiotics support. We reassess clinically and repeat the testing if symptoms are still there. In some cases, you can have a chronic endometritis that does not have any sort of infection present, in which case we work on aggressively managing the inflammation that is present. If we find that there are issues from a standpoint of polyps or fibroids, we are generally referring to a gynecologist for removal of those fibroids or polyps, if they are seemingly causing issues with excess bleeding. If we find that there is cervical ectropion, that is something that we can actually manage right in the office. At the time that we do the exam, we generally will treat with a topical silver nitrate to cauterize that area of inflammation or increased bleeding. And it also tends to help with decreasing the mucus production if it is excessive. So always looking to see again, what is the underlying cause. And finally, and probably most importantly, always, always, always rechecking the labs, reassessing, looking at the charting to make sure that what we have done from a standpoint of intervention is actually moving the needle and changing the symptoms. So couple of questions that I oftentimes get asked when it comes to this premenstrual spotting. If I have a short luteal phase, can I still conceive? The answer is yes. It is absolutely possible to conceive. However you may require additional progesterone support in order to sustain that pregnancy, and ideally, especially if you have had problems with fertility in the past. We want to correct that shortened luteal phase to improve your chances of success with pregnancy. Well, what about if I just have one day of brown spotting before my period starts? Oftentimes, this is completely fine. I generally don't get worked up. If you have one day of spotting that leads into than a normal flow. It's more concerning if we're seeing multiple days before your full flow actually starts, and especially if we start to see that this is a pattern over multiple cycles. Can supplements alone fix the premenstrual spotting. Now, supplements can be helpful in certain cases, but again, most importantly, it needs to be matched to the actual diagnosis. So for example, when we talk about utilizing a supplement like Myo Acetol for insulin resistance, that's fine and it may be beneficial. But if the reason that you have that premenstrual spotting is actually because of a polyp, just treating it with one supplement is not going to be the answer. Most cases where you have premenstrual bleeding or spotting that's happening typically will need medical evaluation in order to at least discern what the cause is. And from there, you can discuss with your healthcare professional what the appropriate treatment is going forward. Imagine if the drawn out spotting or the startup to your period was gone because you found the underlying cause and treated it with a cycle informed plan. Over the next few months, your fertile window would feel more clear. Your luteal phase more predictable, and your monthly cycles calmer and more healthy. Straightforward answers are possible when it comes to premenstrual bleeding, and I would invite you to pay attention to this important vital sign to get the solutions that you deserve to improve your health and promote fertility.

Speaker 2: 17:03

If you're ready to work with our elite team of healthcare professionals, go to our website, radiant clinic.com to schedule a free discovery call and learn more about our package based pricing for comprehensive care. We are currently able to see people for in-person appointments in our Cedar Rapids, Iowa Clinic, or can arrange for a telehealth visit if you live in many different states across the us. Check out our website for current states that we can serve medical clients and let us know if your state is not listed to see if we can still cover you there as we are constantly expanding our reach. Please note that our fertility educators are able to take care of clients no matter where they live. Thank you so much for listening to this episode. Please share this podcast with someone in your life who would benefit from our services. Remember to subscribe to this podcast for more empowering content that I look forward to sharing with you on our next episode of Cycle Wisdom.