Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

Katsushika Hokusai, The Great Wave Off Kanagawa, c. 1831-33

Dear Dr. Pat,

I’m a 48-year-old woman moving into high gear with peri-menopause. I had no period for the past three months, then last night, boom: the flood. I’m not joking—the cramps kept me awake all night, and I’ve bled so much over the past 24 hours that I get light-headed when I stand up. The bleeding is continuing at the same rate on the second day.

Is this normal? Anything I can do to prevent it, or at least make it go easier?

 For the record, I’m 5’8″ and at a healthy weight. I exercise regularly and have no medical problems that I know of. I don’t take any medicine regularly, just calcium and vitamin D.

–Kate

Dear Kate,

Menstrual disorders are one of the most common complaints that women in this part of the menopausal transition experience. I counsel patients that menstrual cycles may be closer together, farther apart, shorter or longer in duration, and heavier or lighter in flow. Many women get lucky. They are the ones who have cycles that become farther apart but shorter in duration and lighter in flow. You may not be one of those.

The most important information that I can give you is that it is a mistake to assume that symptoms are always due to “menopause.” Look for other explanations first. The most common cause of heavy menstrual bleeding is a growth in the uterine cavity. Most of these growths are not malignant, but pre-malignant and malignant causes of bleeding at this age must always be considered. Obesity and use of some drugs may cause abnormal bleeding, but you don’t take any medicine and have a normal weight. A not-yet diagnosed medical problem that makes it difficult for blood to clot properly must also be considered. If the work-up is normal for these causes of abnormal bleeding, then a hormonal imbalance is most likely.

Patients understandably want a quick answer and a quick, inexpensive and effective treatment. We sometimes forget that quick is not always thorough, and that thorough, based on evidence-based medicine, is the right way to care for patients.

Call a gynecologist for an exam urgently. Sometimes patients lose more blood than they realize and often are iron deficient and anemic before the acute blood loss has occurred. Women do get blood transfusions for heavy bleeding on occasion. This can nearly always be avoided by communication with your gynecologist to assess your past tests for anemia and to discuss the amount of bleeding you are experiencing.

Testing

The simple diagnostic tests for the first episode of heavy bleeding are:

• A careful history that includes symptoms like fatigue, dizziness, easy bruising, new nosebleeds, or bleeding from the gums can provide important diagnostic clues. Family history of malignancy or bleeding disorders will be important.

• A thorough physical and pelvic exam is next. These are the talents of a decent diagnostician: take a complete history and do a thorough physical exam. The pelvic exam sometimes reveals a benign mass that can be removed, such as a polyp or fibroid pushing out of the endocervical canal and putting stress on its blood supply, causing a first episode of bleeding. In addition, cervical cancer can be an unlikely but deadly cause of heavy bleeding. If you have had normal pap smears in a timely fashion, it is extremely unlikely that cervical cancer would be the cause of this kind of bleeding.

• Pregnancy test. Yes, I know that pregnancy is unlikely at age 48, but it does happen. Ectopic pregnancy or miscarriage must not be missed.

• Pelvic ultrasound to look for any abnormality in the uterine cavity, such as a polyp, fibroid, or thickening in the lining of the cavity. Ovarian cysts and abnormalities of the uterus can be diagnosed effectively with an ultrasound as well. All of these may be the cause of, or contribute to, this problem of serious menstrual bleeding.

• Blood tests to evaluate for anemia, iron levels, and bleeding disorders, along with liver function tests and thyroid function. These will help with both diagnosis and the development of a treatment plan.

If no abnormalities are found that require further medical or surgical intervention, then an endometrial biopsy to sample the tissue in the uterine lining is the next important step. This is a relatively simple office procedure. It is not as effective as a hospital based procedure known as a D&C, but can provide assurance that treatment can be safely started. Careful observation of your response to the treatment chosen, with the knowledge that the endometrial sample was normal, will be far less expensive in both time and money than beginning with an outpatient operative procedure.

Diagnosis

If no abnormalities are found on the physical exam, and if your blood tests do not reveal a pregnancy, bleeding disorders, or other medical problems that can contribute to heavy vaginal bleeding, and there’s nothing abnormal found with the ultrasound or endometrial biopsy, then the diagnosis is likely to be the expected one: Anovulatory bleeding during the peri-menopause.

This simply means that when a woman misses her period for several months in this hormonal stage, then it’s likely that she has not ovulated. As the ovaries age, ovulation occurs less frequently. But the ovaries still produce estrogen, often in very high levels at some stages of the menopausal transition. During this time, the lining of the uterus is constantly exposed to various levels of estrogen alone. Without the support of ovulation that allows the ovaries to deliver progesterone to the endometrium, this lining of the uterine cavity becomes unstable, and bleeding that is heavy and long often occurs.

Treatment

1. Begin an iron supplement (iron sulfate with Vitamin C to enhance absorption is a good choice) 1-3 times a day, depending on your tolerance for its side effects (largely constipation). Do not take the iron within 4 hours of calcium or dairy products, since calcium and iron bind together in the gut and are not absorbed. Continue the iron supplement until you are one year without menstruation.
2. Start a nonsteroidal anti-inflammatory drug—for example, 800 mg of ibuprofen—three times a day with food just for the time you are bleeding (unless you have a contraindication to the use of these over-the-counter drugs). These drugs are effective in many cases of moderate bleeding when no other cause is found. Take this dose of ibuprofen before the onset of bleeding if possible, and continue until the bleeding stops. It has the added benefit of diminishing period pain.
3. If this type of bleeding becomes a new pattern for you in your unique peri-menopausal journey, there are many options to control the bleeding. Since you have written to me, I will of course, give you my opinion for you to discuss with your personal doctor. Many doctors begin with progestin therapy.

High-dose progestin taken by mouth can be effective for the control of one episode of heavy bleeding. However, if heavy bleeding becomes a new pattern for you, studies show that in order to be effective, these high dose progestin pills must be taken daily for 21 days each month in order to control this problem. When the progestin therapy ends each month after its 21-day use, then many women have a much more normal bleeding pattern in response to the withdrawal of the progestin. The problem with this treatment is that women often hate the side effects: bloating, water retention, constant PMS symptoms. Other people around them may not like it, either!

If longer-term therapy is thought necessary, there is a very effective intra-uterine device that is coated with progesterone, the LNG-IUS, (Mirena). This delivery system for progesterone targets the lining of the uterus and is generally well tolerated. It is not as inexpensive as progestin pills, but almost none of the progesterone is absorbed into the body. It has the added benefit of providing contraception. And it is certainly less expensive and has less risk than hospital-based procedures, such as destruction of the endometrial lining (ablation) or hysterectomy.

The oral contraceptive has been a great favorite of gynecologists and the pharmaceutical industry for the treatment of heavy, frequent and otherwise abnormal bleeding in women in their 40s and sometimes, God help me, in their 50s. I do not recommend this form of hormonal treatment in women past 45. And if a woman in her mid-40s chooses to use this form of hormonal management for control of abnormal bleeding, then I do blood tests that evaluate each woman’s risk for blood clots, in order to determine if she has more risk of a blood clot, stroke, or cardiovascular event than the average woman this age. It is a great form of contraception for young women and even older women up to a point, as long as doctor and patient understand that there are clear contraindications to the use of the birth control pill, and that these should never be ignored. These pills contain estrogen and progestin, so the impact on breast cancer risk in an older woman must always be considered. No woman over 40 should start an oral contraceptive pill without a current mammogram and a normal clinical breast exam.

These are the first-line treatments for a woman your age who has experienced her first episode of severe vaginal bleeding after no menstrual cycles for a few months.

Remember that new symptoms must always be evaluated. You know a great deal now about the importance of a good history, complete physical exam, appropriate diagnostic workup and treatment options that are effective. You will help your doctor choose what is best for you and then as a team you will monitor the response.

Physiological change in the menopausal transition will cause many alterations in hormonal, physical and emotional aspects of life, but it is not the cause of every symptom in a woman past 40.

Patricia Yarberry Allen, director of the New York Menopause Center, is a gynecologist affiliated with New York-Presbyterian Hospital and a board-certified fellow of the American College of Obstetrics and Gynecology. She is a spokesperson on women’s health, and the publisher of Women’s Voices for Change.