The ESK blog
Heavy periods and perimenopause?
19 August 2024
Dr Anne Thomson
What’s a normal period?
A normal menstrual cycle lasts 4-9 days with a blood loss of less than 80 mls. So any period that lasts longer and has more bleeding than 80mls from start to finish is defined as “heavy menstrual bleeding” (what we USED to call menorrhagia.)
A recap on hormonal changes during perimenopause During a woman's menstrual cycle, two major hormones are at play: oestrogen and progesterone. These hormones are produced by the cells surrounding the eggs. Oestrogen helps the uterine lining grow, while progesterone, produced during ovulation, controls the growth of this lining. An imbalance of these hormones—too much oestrogen and not enough progesterone—can lead to heavier and more problematic periods.
As perimenopause progresses, oestrogen levels decrease, causing the uterine lining to become thinner. Ovulation becomes less frequent, and periods gradually become lighter and less frequent until they stop altogether. This is a time characterised by oestrogen deficiency.
Heavy Menstrual Bleeding (HMB). One in three women experience HMB during perimenopause, often sporadically occurring with normal or even light periods in between. HMB may simply be a symptom of perimenopause but it’s important to consult a healthcare professional as it could indicate more serious health conditions.
Causes of HMB Most causes of HMB are benign, including simply not ovulating, uterine polyps, fibroids, adenomyosis, low thyroid function, and other medical conditions. However, HMB can also be a sign of cancer of the uterine lining (endometrial cancer), which, while really uncommon, must be diagnosed early. Other cancers such as cervical cancer can also cause HMB.
Ovulatory vs. Anovulatory Bleeding HMB can be ovulatory or anovulatory. Ovulatory bleeding occurs when a woman is still producing eggs and is often associated with premenstrual symptoms and sometimes painful periods. Anovulatory bleeding, more common during perimenopause- especially in the later stages of peri, is linked to prolonged periods and heavier flow.
When to See a Doctor You should visit a doctor if you experience any of the following:
- Bleeding that requires a new pad every hour for over 24 hours
- Bleeding that lasts over two weeks
- Any bleeding after your final menstrual period, bleeding between periods or bleeding after sexual intercourse
Keeping a record of your symptoms can help your healthcare professional with examination and diagnosis.
Diagnosing HMB We will usually start with a pelvic ultrasound and depending on what we find, go from there. You might also need a blood test to check for iron deficiency and even an underactive thyroid.
Managing HMB: Treating HMB seriously depends on getting the diagnosis correct and tailoring the treatment to the underlying cause. Assuming no specific cause is found, here are some options:
- Healthy Lifestyle: Maintain a healthy weight, a balanced diet, regular exercise, avoid smoking, and manage stress.
- Increase Iron Intake: To combat the iron deficiency that inevitably arises from blood loss, eat iron-rich foods like spinach, red meat and eggs, or take iron supplements.
- Hormone Therapy: Oral contraceptives or daily progesterone can help decrease heavy bleeding and regulate menstrual cycles.
- Intrauterine Device (IUD): An IUD containing progesterone can control uterine bleeding and provide effective contraception.
- Tranexamic acid: Tranexamic acid, allows blood to clot more easily. It can reduce the amount of blood lost by 50% although it generally won’t reduce the number of days of bleeding.
Next Steps If you have concerns about perimenopause or HMB, consult your healthcare professional. They can help you explore options for diagnosis, prevention, symptom management, and treatment. Treatment options may include hormonal therapy, D&C procedures, polypectomy, myomectomy, endometrial ablation, or, as a last resort, hysterectomy.
I hope this information helps you understand perimenopause and how to manage its symptoms. Remember, you’re not alone, and there are many options available to help you through this transition. Feel free to reach out if you have any further questions or concerns.