July 23, 204 – Nicole Pauzano’s perimenopausal bleeding can get so bad, she can’t always go to work the day it starts.
“I’m bleeding through ultra-tampons in less than 2 hours to the point where they’re completely saturated, and I'm bleeding beyond backup pads into my clothing,” said Pauzano, a 49-year-old school psychologist.
Perimenopause – the time 6 or 7 years before and a year after menstruation ends – is a time for mood swings, sleep disturbances, hot flashes, night sweats, and for some women, excessively heavy menstrual bleeding (also called abnormal uterine bleeding or ‘the menopausal flood’). Short of sitting on a towel in the car, taking an extra set of clothing to the office or meeting, or staying home and waiting it out, there are steps that can be taken.
The trouble is, perhaps as many as a third of women never find their way into a doctor’s office or even know that it’s an option. This is an important reason why the true number of women who get excessive bleeding is unclear. Nevertheless, the horror stories are pervasive.
Susie Parker, a 49-year-old PR consultant, said that until she had an ablation (a procedure that destroys or removes the lining of the uterus), she had very heavy, painful periods, starting around age 40.
“They were very debilitating in the sense that I could not really leave the house without feeling like I might have some sort of accident out in public,” she said. “It was affecting my quality of life, where I could go, and what I could do in terms of my lifestyle, and I was also anemic.”
#StopSuckingItUp
From a medical perspective, excessively heavy menstrual bleeding describes a menstrual flow that is outside the “norm” in terms of volume, duration, regularity, or frequency. It can be debilitating, not to mention frustrating, especially when it comes to seeking care.
“As recently as a month ago, I treated a patient … who sadly had 8 months of heavy bleeding; she literally had bled menstrual fluid into her shoes,” said Lisa Taylor-Swanson, PhD an integrative health specialist, acupuncturist, and assistant professor at the College of Nursing at the University of Utah in Salt Lake City. “She went to her primary care doctor, and he said that ‘this was what happens during perimenopause’ and didn’t treat her,” Taylor-Swanson said.
This experience may not be unusual. “For so long, women have been told it’s just the way it is,” said Sophia Yen, MD, MPH, co-founder and chief medical officer of Pandia Health, a Sunnyvale, CA-based telehealth company that provides birth control and menopause care. She said that as a woman who is also now going through menopause and someone whose close friends have turned to for help, “women should ‘hashtag-stop-sucking-it-up.’”
Her advice?
“If you see giant clots greater than the size of a quarter, if you’re going through more than a pad (or tampon) an hour, if it’s unusual for you specifically, then it’s definitely something to be concerned about. If you have any bad bleeding, please see a doctor to have it worked up,” Yen said.
Marisa Messore, MD, a certified menopause practitioner and a women’s sexual health consultant based in Miami Beach, FL, agreed.
“Excessive menopausal bleeding can be due to many things – it could be related to hormonal changes or fluctuations, but there could also be other things that are going on that need to be evaluated, like structural problems with the uterus, polyps, etc.,” she said. It’s also important to rule out pregnancy.
Other potential causes include blood clotting issues, thyroid problems, or even cancer, which is why seeking out a full evaluation is important. Excessive blood loss might also lead to anemia (low levels of red blood cells), which affects about 58% of women who had perimenopausal bleeding.
Whenever possible, the best type of practitioner to seek for a diagnostic workup – starting with lab work – is someone who is trained and specializes in menopause and gynecology, but these people are not always easy to access. According to the Menopause Society (previously called the North American Menopause Society), there are 3,000 certified menopause practitioners across the globe. Though the organization no longer quantifies practitioners by country, at last count, less than half resided in the U.S. What’s more, findings from a 2023 survey among OB/GYN residents' program directors showed that only 31% included menopause in their curriculum.
Yen suggested that before seeing any practitioner, you might wish to keep track of the number of days with excessive bleeding, and the number of pads or tampons per day, type (light, super, ultra). The information can be tracked in phone notes or on one of the Menopause Society's free and accessible menstrual bleeding calendars.
Another consideration is: How much blood is too much?
“There’s quite a bit of data showing that women who are 50 bleed 6 milliliters more than women aged 20 to 45; some bleed as much as 133 ml (the accepted definition is 80 ml or more),” said Taylor-Swanson.
Stopping the Flood
Treatment goals for the menopausal flood range from regulating menstrual cycles and lessening blood loss to improving overall life quality. Selection is often based on things like fertility desire and the presence of other medical conditions.
Hormonal options are often the first line of treatment.
“We’re in a time of more personalized medicine, and we want to tailor treatments for the patient and to their specific symptoms, look at their entire medical history, and if they are a candidate for hormonal therapy,” said Messore.
“I believe in options, and so, knowing that it is an option to turn off your periods as you head into this rocky period, particularly if you have heavy bleeds,” Yen said. “A lot of physicians are personally on IUDs, which result in no periods in 30%, and in lighter periods in 70%.”
Her strategy is “to go into menopause on hormones so you don’t have to go through this irregular bleeding,” she said.
Progesterone-releasing IUDs are also used in women who might not have taken preemptive actions.
Another option includes progesterone only pills (POPs) or estrogen/progesterone pills (better known as oral contraceptives), which Yen said not only help address heavy periods, but may also help with conditions like endometriosis, polycystic ovary syndrome, acne, and more stable moods.
Other medical options are geared toward reducing inflammation, such as over-the-counter medications, those that help slow bleeding (tranexamic acid), and endometrial ablation.
Taylor-Swanson also stands behind acupuncture.
“The role of acupuncture therapy is to help the body stay in the middle of the road in terms of cycle regulation – not too heavy, too light, too frequent, not too far apart,” she said, adding, “I can say without hesitation that acupuncture is a very safe intervention with minimal side effects.”
Though acupuncture takes a whole-body/whole-person, individualized approach, Taylor-Swanson shared that for periods especially, she typically provides weekly acupuncture until there is a normal period, then every other week, and see how it goes to the next cycle. If that is acceptable, “I then try one treatment in the course of a month, especially if pain is also involved,” she said.
Regardless of which treatment you choose, it’s important to find a practitioner who not only can discuss your symptoms but come up with a plan for the entire transition, Messore said. “It can take a few years; it’s not a one-stop thing; it’s a process,” she said.
