Experiencing changes in your menstrual cycle can be unsettling as you enter the perimenopausal stage. Heavy menstrual bleeding during perimenopause is common. Estrogen and progesterone levels can fluctuate in this phase, which can lead to more intense and irregular bleeding. Often my patients have concerns about very heavy periods or an intensity in blood loss that is not normal. If your period flow is affecting your quality of life, this is something you need to discuss with your primary care provider.

You might notice that periods become more unpredictable, with some lasting longer or are heavier than before. Not all women experience significant bleeding, but for those who do, it can affect daily activities and quality of life. Options for managing heavy bleeding include lifestyle changes and medical treatments, which can help reduce discomfort and maintain normal activity levels.

The key to dealing with these changes is knowing what to expect and exploring your options for relief. From nutritional changes to medical interventions, there are ways to handle heavy bleeding. It's important to consult with a healthcare provider to find the best approach tailored to your needs, ensuring you navigate perimenopause with greater ease and confidence.

Understanding Heavy Menstrual Bleeding

Heavy menstrual bleeding (HMB) during perimenopause can cause significant discomfort and affect various aspects of your life. It's important to recognize the symptoms and understand how they might impact your daily activities and overall well-being.

What is HMB?

Heavy menstrual bleeding (HMB), also known as menorrhagia, involves excessive blood loss during your menstrual period. A typical sign is soaking through a pad or tampon every hour for several consecutive hours. You might also notice blood clots larger than a quarter during your period. If these symptoms persist, it's important to talk to a healthcare provider for guidance.

"Heavy menstrual bleeding (HMB) is excessive menstrual blood loss that interferes with women's quality of life, regardless of the absolute amount of bleeding. It is a very common condition in women of reproductive age, affecting 2 to 5 of every 10 women." (Rodrigues, et al. 2022)

Impact on Quality of Life

Heavy menstrual bleeding can significantly impact one's daily life, affecting both your physical and emotional well-being. You may experience fatigue due to blood loss, leading to decreased energy levels and an inability to engage in regular activities.

Low iron levels (also known as iron deficiency anemia) is a common result of extended periods of heavy bleeding, which can further exacerbate feelings of tiredness and weakness.  Low iron levels is an important health aspect that needs to be corrected and addressed. Emotionally, low iron can cause anxiety or stress about bleeding unexpectedly in public or during important events - this is how it impacts women's lives hugely in a negative way.

If you're encountering these challenges, speak to your health care provider to find solutions for your health concerns. This could greatly improve your quality of life during the perimenopausal phase.

Perimenopausal Hormonal Changes

During perimenopause, your hormones, mainly estrogen and progesterone have major fluctuations in their normal cycling patterns.

These changes can begin in your 40s, although some women can begin to experience changes in their hormones in their late 30's. Fluctuating estrogen levels often cause hot flashes, night sweats, and irregular periods. Progesterone levels also decline if there is no ovulation, which can affect your mood and sleep patterns. Understanding these changes can help you manage symptoms better. If symptoms become troublesome, consult your healthcare provider for guidance.

Hormonal changes are a common cause of heavy bleeding with clots after age 40. A hormonal imbalance can lead to excessive growth of the uterine lining. Other potential causes include uterine fibroids or polyps.

Perimenopause can last between a few months to about 10 years, with an average duration of 4 years. It typically progresses through several stages. Early perimenopause begins with irregular menstrual cycles. As it advances, cycles may become more erratic, and bleeding can become heavier. The late stage is marked by a longer span without menstruation in the menopausal transition. Recognizing these stages helps in anticipating what changes might occur next and in planning appropriate management strategies.

Causes of Heavy Menstrual Bleeding in Perimenopause

Heavy menstrual bleeding during perimenopause can result from various factors.  The first thing to rule out is possibility of pregnancy. If this has been ruled out (this is for women of reproductive age and should be ruled out by blood test and/or urine test), then there are other diagnoses that need to be made by the health care provider.  A helpful acronym used to diagnosis causes of abnormal uterine bleeding (AUB) is termed: PALM-COEIN. This acronym stands for the following causes which your primary care provider can use to diagnosis the cause of bleeding.

Structurual causes:

P: Polyp

A: Adenomyosis

L: Leiomyoma (uterine fibroid)

M: Malginancy/Hyperplasia 

Non-structural causes:

C: Coagulopathies (clotting disorders)

O: Ovualatory disorders (e.g PCOS)

E: Endometrial 

I: Iatrogenic

N: Not otherwise classified (e.g. C-section scar defect)

"The PALM - COEIN classification effectively categorizes etiological factors related to abnormal uterine bleeding in perimenopausal women, aiding in diagnosis and treatment." (Vidya, 2023)

Structural causes of AUB: PALM

Polyps, adenomyosis, and leiomyomas, are non-cancerous changes on the uterine lining.  They can increase bleeding by creating an irregular surface for shedding. These conditions can often be diagnosed through medical tests such as transvaginal ultrasound and may require treatment like medication or surgical intervention. Malignancy and hyperplasia need to also be diagnosed via testing to rule out other conditions. 

Non-Structural causes of AUB: COEIN

Clotting Disorders

Blood clotting disorders can also lead to increased menstrual bleeding. Conditions that affect how well your blood clots, such as Von Willebrand disease, may cause you to experience heavier periods. These disorders affect the proteins in your blood that are responsible for clotting, hence your bleeding may be prolonged or more intense.

Often, these disorders are inherited, meaning if you have a family history, you might be at risk. Diagnosis typically involves blood tests, which measure the clotting proteins and platelets. If you have a clotting disorder, treatments may include medications that help your blood clot more effectively.

Ovulatory Dysfunction

Ovulatory dysfunction is another factor that can affect menstrual bleeding during perimenopause. During this time, your ovulation may become irregular or stop altogether. This can lead to periods where the endometrial lining builds up more than usual, because the usual cycle of buildup and shedding is disrupted.

Endometrial Causes

The endometrium, or the lining of the uterus, can play a significant role in heavy bleeding during perimenopause. An overgrowth of the endometrial tissue, known as hyperplasia, can lead to excessive bleeding. This can be due to hormonal imbalances, particularly increased levels of estrogen without adequate progesterone.

Such conditions may cause the endometrial lining to thicken and not shed properly during your menstrual cycle, leading to heavier periods.

Without proper ovulation, progesterone levels drop, which can lead to heavy bleeding once menstruation occurs. This lack of regular ovulation is common in perimenopausal women and is often managed by hormone therapy. Understanding how your cycle is impacted can help in managing these symptoms more effectively.

Iatrogenic and Not otherwise classified causes

Conditions that do not fall under any of the conditions listed above fall under one of these two remaining subcategories. Conditions such as use of medications like anti-virals or corticosteroids like dexamethasone could cause bleeding. These conditions are under this category.

Diagnosing HMB

Diagnosing menorrhagia, especially during perimenopause, involves evaluating symptoms and using medical tools. Key diagnostic steps include discussing medical history, a physical exam, laboratory tests, and imaging studies.

Medical History and Physical Exam

Your doctor will begin by asking about your menstrual cycle, such as the length and flow of your periods. This helps in understanding if the bleeding is unusually heavy compared to your typical cycle.

The physical exam often includes a pelvic exam to check for any signs of abnormalities in the uterus or cervix. The doctor may look for symptoms such as pain, swelling, or unusual discharge. This step is crucial to rule out other potential causes of heavy bleeding, like fibroids or endometriosis.

Laboratory Tests

Blood tests can provide important insights. A complete blood count (CBC) and ferritin blood test can reveal anemia caused by heavy bleeding. Other tests might include hormone levels, such as follicle-stimulating hormone (FSH) to assess if menopause is approaching, or thyroid stimulating hormone (TSH) tests, since thyroid imbalances can impact menstrual cycles.

Doctors may also check for bleeding disorders, which are less common but possible. For example, checking for Von Willebrand Disease can be important, especially if there's a family history of bleeding issues.

Imaging Studies

Imaging studies are often used to get a clearer view of the uterus and other pelvic organs. A transvaginal ultrasound (TVU) is common. It helps visualize the uterus, identifying issues like fibroids or polyps that might cause heavy bleeding.

In some cases, a hysteroscopy might be recommended by your family doctor or gynecologist. This procedure involves inserting a thin, lighted tube to view the inside of the uterus directly. 

Treatment Options

Heavy menstrual bleeding during perimenopause can be managed through various treatments. You may consider medication, minimally invasive procedures, or surgical options depending on your specific needs and your healthcare provider’s advice.

Medications

To manage heavy bleeding, treatment varies depending on the cause, however the Intrauterine Device (IUD) e.g. Mirena is considered first line treatment, followed by medications. Non-steroidal anti-inflammatory drugs (NSAIDs) can reduce bleeding and relieve pain. Birth control pills can regulate your cycle and decrease bleeding. In some cases, progesterone therapy is used to balance hormone levels and manage bleeding effectively. Additionally, a medication called Tranexamic acid (TXA) is sometimes prescribed, which helps reduce menstrual blood loss.

"Intrauterine levonorgestrel is the most effective medical therapy for perimenopausal women with heavy menstrual bleeding, but other options are also effective." (Duckitt, 2007)

Minimally Invasive Procedures

If medications are not sufficient, minimally invasive options such as endometrial ablation might be considered. This procedure involves removing or destroying the lining of the uterus to reduce or stop bleeding. It's typically done on an outpatient basis, requiring little to no recovery time at home. 

These procedures are less invasive than surgery yet still provide substantial relief for many women.

Surgical Treatments

In certain situations, surgical treatments like hysterectomy may be recommended. This involves removing the uterus and is considered when other treatments don't work or when there are additional conditions like fibroids. A myomectomy might be performed if you have fibroids but want to preserve your uterus. Although more invasive, these options offer a permanent solution to heavy bleeding. They require significant recovery time and should be discussed thoroughly with your healthcare provider to understand the risks and benefits.

Surgical treatments usually result in a full resolution of heavy bleeding issues but treatment varies and should be discussed with your family doctor of gynecologist.

Heavy menstrual bleeding during perimenopause can lead to various concerns. Addressing treatment options, causes, and natural management methods help you understand what to expect and when to seek medical advice.

You should be concerned if you're soaking through pads or tampons every hour for several hours, or if your period lasts longer than a week. If you experience symptoms like dizziness, fatigue, or shortness of breath, it's important to consult a healthcare professional.

Natural ways to manage HMB

Natural management options include dietary changes and targeted supplementation can aid the individual.

Increasing dietary intake of iron-rich foods such as:

1. poultry

2. fish/seafood

3. red meat 

4. dark leafy greens (e.g. spinach, rapini, kale, etc.)

5. lentils/beans

Iron supplementation may also be required on top of an iron rich diet.  There is also evidence that ginger and Boswellia (commonly known as frankincense) when taken in the days prior to a period as well as during the period that it can decrease the amount of blood loss. Treatment with natural means however should not be used without proper diagnosis and investigation into the cause of HMB.

"Both ginger and frankincense have been shown to reduce the amount and duration of menstrual bleeding effectively. However, the improvement in quality of life was more pronounced in the groups receiving these herbal treatments compared to the placebo group, indicating their potential as complementary treatments for HMB." (Eschinger, et al. 2019)

While changes in cycle length and flow are typical during perimenopause, bleeding that lasts longer than two weeks is not considered normal and should be evaluated by a healthcare provider. This could indicate other health issues that need attention.

As menopause approaches, hormonal fluctuations can cause changes in menstrual flow, sometimes leading to heavier periods. These changes are often temporary, but any significant or prolonged increase in flow should be discussed with your doctor.

If you would like to book a free discovery call with Dr. Amy Tung, ND you can book here.

To your best health,

Dr. Amy Tung, ND

Naturopathic Doctor

Menopause Society Certified Practitioner

References:

Anjum, S., & Dhiman, K. (2021). Management Of Menstrual Problems In Perimenopausal Women-A Case Report. , 04, 27-33. https://doi.org/10.47223/IRJAY.2021.43012.

Chaudhry, S., Berkley, C., & Warren, M. (2012). Perimenopausal vaginal bleeding: diagnostic evaluation and therapeutic options.. Journal of women's health, 21 3, 302-10 . https://doi.org/10.1089/jwh.2011.2949.

Duckitt, K. (2007). Medical management of perimenopausal menorrhagia: an evidence-based approach. Menopause International, 13, 14 - 18. https://doi.org/10.1258/175404507780456782.

Eshaghian, R., Mazaheri, M., Ghanadian, M., Rouholamin, S., Feizi, A., & Babaeian, M. (2019). The effect of frankincense (Boswellia serrata, oleoresin) and ginger (Zingiber officinale, rhizoma) on heavy menstrual bleeding: A randomized, placebo-controlled, clinical trial.. Complementary therapies in medicine, 42, 42-47 . https://doi.org/10.1016/j.ctim.2018.09.022.

Payon, H., Hannisa, S., & Yati, A. (2024). Pengaruh Pemberian Susu Kedelai Terhadap Tingkat Tekanan Darah Pada Wanita Perimenopause Di Desa Ensalang Tahun 2022. Protein : Jurnal Ilmu Keperawatan dan Kebidanan. . https://doi.org/10.61132/protein.v2i1.155.

Rodriguez, M., Dias, S., Jordan, V., Lethaby, A., Lensen, S., Wise, M., Wilkinson, J., Brown, J., & Farquhar, C. (2022). Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis.. The Cochrane database of systematic reviews, 5, CD013180 . https://doi.org/10.1002/14651858.CD013180.pub2.

Selvam, V., & Lakshminarayanan, P. (2024). A Comprehensive Approach: Correlating Ultrasound Imaging with Endometrial Histopathological Analysis in Perimenopausal Women with Heavy Menstrual Bleeding.. Cureus, 16 3, e57201 . https://doi.org/10.7759/cureus.57201.

Vidya, S. (2023). Categorization of Peri - Menopausal Women with AUB according to PALM - COEIN FIGO Classification. International Journal of Science and Research (IJSR). https://doi.org/10.21275/sr23314125539.

Disclaimer:

The information in this blog is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of your doctor or other qualified health professional with any questions regarding a medical condition or treatment. Never disregard professional medical advice or delay seeking treatment because of something you have read in this blog.

Individual results may vary, and the strategies discussed here are not guaranteed to work for everyone. This content does not create a patient-client relationship and should not be used as a replacement for personalized medical care.