By Leanna Coy, FNP
Many women begin to have menstrual changes in their 30s and 40s that don’t relate to childbirth. Often these menstrual changes get pushed aside as related to work or family stress, travel, or relationship issues. When someone starts to have fatigue along with heavier bleeding, they may tell themselves that it’s still related to stress and lack of sleep.
Each woman’s “normal” menstrual bleeding is a little different. When the timing, frequency, severity, or duration of menstrual bleeding changes outside of pregnancy, it is called abnormal uterine bleeding (AUB). Perimenopause is a common time for heavy AUB to occur.
In perimenopause bleeding patterns to begin to change due to hormone shifts and physical changes to the uterus or ovaries. Some periods are benign and can be managed conservatively. Others can be a sign of a health problem that needs addressed. We’re going to review how to know the difference and what you can do to manage symptoms.
Signs of abnormal heavy periods
In perimenopause many women who have AUB experience heavy menstrual bleeding. Long-term heavy bleeding can cause anemia that may start mildly with some fatigue that worsens. As it progresses someone can have dizziness, shortness of breath, and may begin eating ice—known as pica eating. These signs should be ignored.
Symptoms of a heavy period include:
- Needing to change soaked full-sized pad or tampon every 1-2 hours or empty a menstrual cup more often than recommended
- Needing to use both a tampon and pad at the same time
- Periods lasting longer than 7 days
- Passing blood clots larger than a quarter
- Bleeding through your clothing or bedding
- Avoiding activities or taking time off work due to the bleeding
Up to one-third of women will experience AUB during their lifetime.
What causes heavier periods in perimenopause
It is not wrong thinking that stress can trigger changes to a period. But in perimenopause the hormone changes are often the cause for heavy periods. During the menopause transition estrogen and progesterone levels begin fluctuating somewhat erratically. These changes can cause the heavy bleeding and irregular period timing. Low thyroid function is another hormone trigger for bleeding changes. About 1 in 4 women begin having thyroid problems between the ages of 40 and 55 years.
Physical changes to the uterus can impact bleeding. Often the physical changes relate to the lining of the uterus (endometrium). Some physical changes that can trigger heavier bleeding include:
- Uterine polyps: growths in the lining of the uterus
- Uterine fibroids: benign tumors growing in the uterus muscle
- Adenomyosis: when the lining of the uterus breaks down and grows into the uterine muscle
The most concerning cause of AUB is endometrial cancer, which is a cancer of the uterine lining. About 1 in 1000 women will develop endometrial cancer. This is often found during perimenopause but is more commonly associated with postmenopausal bleeding.
Risk factors for endometrial cancer include having obesity, diabetes, polycystic ovarian disease, and entering menopause later (after age 55). These risk factors are associated with the body producing excess estrogen with little or no progesterone to buffer the estrogen. In rare cases, heavy menstrual bleeding can indicate the presence of uterine cancer.
What to do if you’re having heavier periods in perimenopause
If you are over age 40, take any abnormal bleeding seriously. It’s best to talk with your healthcare provider about any new or heavier menstrual bleeding. They may want to do an assessment to look for any concerning causes. An assessment can include:
- Blood tests to assess hormone levels and look for anemia
- An ultrasound of the uterus to look for abnormal growths or changes to the lining of the uterus
- Biopsy of the uterus to check for cancer
Treatment for AUB depends on the underlying cause and patient preference.
When the cause for bleeding is caused by changes to ovulation or dysfunction of the uterine lining, non-steroidal anti-inflammatory medications (NSAIDs), such as ibuprofen and naproxen, can help reduce heavy bleeding and any associated cramping. With NSAIDs it is important to not exceed the recommended dose and avoid taking on an empty stomach.
Hormone therapy in the form of birth control can decrease heavy bleeding and help regulate menstrual cycles that may change during the menopause transition. Hormonal birth control is not advised for anyone over the age of 35 who smokes cigarettes due to the increased risk of blood clots and stroke. Other risk factors to discuss with your healthcare provider before starting hormonal birth control include your age, risk of heart disease, other medications, and breast cancer.
In more severe cases, your healthcare provider may recommend a surgical option. These can include:
- Dilation and curettage (D and C) to remove the lining of the uterus
- Removal of fibroids or polyps
- Endometrial ablation to permanently thin the lining of the uterus
- Hysterectomy to completely remove the uterus
Hysterectomies are not done as often as they were in the past due to newer treatment options. This option is often a last resort used when other treatments have not worked. Women may also choose this option if the bleeding significantly affecting their quality of life and they aren’t planning any future pregnancies.
Heavy menstrual bleeding is not just inconvenient. Often, it is problematic. Missed work or not having the energy to function normally can have a huge impact on your finances and quality of life. This is not something you need to “just deal with.” If you are having heavy menstrual bleeding or changes to your periods that concern you, schedule an appointment with your healthcare provider to get checked and to discuss a treatment that works best for you.