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.

Dear Dr. Pat

I am 46 years old and have had a change in my menstrual cycle. My periods became farther apart but heavier.  After no period for four months, I had a  flood. Of course it was on the weekend! The cramps kept me awake all night, I passed some small clots and I bled so much over the first 24 hours that I got light-headed when I stood up. I bled through a tampon and pad every two hours for the second day.  After this I had staining for a week.  I know I am the right age to be thinking about menopause but is this normal bleeding for this time? Anything to prevent it, or at least make it go easier? For the record, I’m not overweight, I eat well and exercise. I had bad insurance until I recently got a job with better insurance. Before I had to get a referral from my primary doctor to see a gynecologist so I didn’t really have anyone to call. Now, I can make an appointment with a gynecologist on my plan directly.   I have no other medical problems that I know of. I don’t take any medicines regularly, just calcium and Vitamin D.

—Kate

Dr. Pat Responds

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 in this reproductive stage, menstrual cycles may be closer together, farther apart, shorter or longer in duration, and heavier or lighter in flow. Many women get lucky with cycles that become farther apart but shorter in duration and lighter in flow.  You, however, did not get lucky and are experiencing  serious menorrhagia (heavy vaginal bleeding).

It is a mistake to avoid seeking evaluation in a timely fashion and to  assume that any new or unusual symptoms in the 40s and 50s are always due to “menopause.” I can understand that seeing a primary care doctor just to get a referral to the right gynecologist for a woman in mid-life could seem overwhelming.  However, you must find a gynecologist now, develop a relationship with this doctor and get an evaluation, diagnosis and treatment plan.  I hope this discussion of causes of perimenopausal bleeding, evaluation, diagnosis and treatment options will help you prepare for your visit to a gynecologist. If you have another episode of heavy bleeding before you see a gynecologist, you must be seen in an emergency department. Sometimes patients lose more blood than they realize and are often iron deficient and anemic even before such an acute blood loss has occurred. Women do get blood transfusions for heavy bleeding on occasion. along with emergency surgeries. This can nearly always be avoided by communication with a gynecologist, who can do the right urgent evaluation and treatment followed by a more thorough evaluation and management strategy when the emergency has passed.

Causes

The most common structural causes of heavy bleeding are fibroids and polyps. They are the cause of heavy bleeding in about 40 percent of women and include:

1. Fibroid tumors of the uterus. These are uterine muscle tumors that may impede the ability of the uterus to contract effectively, increasing the likelihood of heavy and prolonged bleeding. When there is an extension of the fibroid into the endometrial cavity, known as a submucous fibroid, the bleeding may be even more significant. Fibroids are almost always benign (not cancerous). Rarely (less than one in 1,000), will a cancerous fibroid occur. This is called leiomyosarcoma. Doctors think these cancers do not arise from an already-existing fibroid.
2. Adenomyosis of the wall of the uterus. This condition is a form of endometriosis in which the lining of the uterus, known as the endometrium, becomes part of the muscular wall of the uterus.  This abnormally located endometrial tissue impedes the ability of the uterus to contract normally, producing longer and heavier periods.
3. Endometrial growths. These are often benign polyps, but  pre-malignant and malignant growths must be considered. Polyps do tend to become more common as we age.
4. Endometrial thickening. Can result from benign or malignant change.
5. Other medical problems. Any previously undiagnosed conditions that could cause bleeding disorders should be considered.
6. Hormonal change. Forty percent of women bleed heavily due to hormonal change that results from perimenopausal alterations in the endocrine system such as fluctuations of estrogen and progesterone, two key female hormones. Obesity, another cause of heavy bleeding, is also hormonally based. Women who are overweight often have issues with abnormalities in their period due to the presence of fat stores in the stomach, abdomen and buttocks that make a chemical called androstenedione that is changed into estrogen. This causes the patient to have more estrogen surges that are not properly balanced by cyclic production of appropriate amounts of progesterone from the post ovulation ovaries.

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