For perhaps three decades of their lives or more, women are accustomed to the monthly bleeding associated with their menstrual cycle. When bleeding patterns change -- as they inevitably will for every woman -- most differences are subtle and benign signs of menopause. But some, such as heavy bleeding, may require medical attention.
The first noticeable change is usually erratic periods that occur some months but not others as ovarian function declines. This can go on for months or years in a phase called perimenopause. Still, the length and flow of uterine bleeding -- a highly individual trait that can be long or short, heavy or light for any given woman -- tends to remain fairly predictable when periods do arrive.
When should alarm bells go off? Whenever that blood flow changes significantly -- especially toward heavy bleeding that differs greatly from previous flow, says menopause expert Cynthia Stuenkel, M.D., clinical professor of medicine at the University of California, San Diego. "Having things be off schedule a bit is probably normal," Stuenkel says, "but women kind of know what their normal pattern is. A departure from that should be checked out.''
Passing large clots, experiencing dizziness or fatigue from extra blood loss, or needing to awaken several times a night to change pads or tampons should also be reported to the doctor, as these symptoms indicate abnormally high blood loss.
And women who have already gone through menopause -- a complete cessation of periods for 12 months or longer -- should consult their doctors promptly if they experience any vaginal bleeding, as it can signal uterine or cervical cancer.
Causes and Effects
Abnormally heavy bleeding occurs in one-third of women during their reproductive years and has many possible causes. These include uterine fibroids or polyps, which are benign growths; endometriosis, in which the uterine lining grows in locations outside the uterus; bleeding disorders; certain medications, such as blood thinners; pelvic infections; or uterine or ovarian cancer, the risk of which increases after the age of 45.
The most common reason for heavy bleeding during perimenopause, however -- accounting for 70% of all such cases -- is hormone-related. Called anovulation, it happens when the ovary withholds an egg but continues releasing estrogen, which is not balanced by the progesterone normally secreted by a mature egg. Because of this, the uterine lining thickens greatly and sheds in an unpredictable manner, causing irregular and/or heavy bleeding.
The toll of this condition goes beyond the obvious discomfort and inconvenience of frequent pad or tampon changes and worry of bleeding through clothing. Prolonged, heavy blood loss can lead to anemia, or low iron levels that cause chronic fatigue. A sudden, significant loss of blood can cause fainting or extreme weakness.
Heavy bleeding can interfere with a woman’s sex life, athletic activities or even her work life. According to the Association of Reproductive Health Professionals, women with heavy periods lose about $1,700 a year in wages and work about 3.6 fewer weeks annually.
A number of simple diagnostic tests, many of which are non-invasive and involve an office visit, can determine the cause of abnormal bleeding. These include a vaginal ultrasound, which transmits an image of the uterine lining thickness and any tissue abnormalities, such as fibroids or malignancies; an endometrial biopsy, which procures a small sample of the uterine lining through a catheter inserted through the cervix; and a hysteroscopy, which involves inserting a camera into the uterus through a thin tube.
Additionally, doctors may perform a blood test on women with heavy bleeding to determine if they have a bleeding disorder or suffer from anemia.
Medications are the first-line remedies for abnormal bleeding, including birth control pills that can regulate period length and flow. A relatively new intrauterine device (IUD) is also available that not only is an extremely effective form of birth control but releases a hormone that thins the uterine lining.
surgical options are considered if medications don’t work satisfactorily. These include procedures such as endometrial ablation, which uses heat, electricity or cold to destroy the uterine lining; or hysterectomy, an operation to remove the uterus, and sometimes the ovaries and cervix as well.
Hysterectomies, which 600,000 American women undergo annually, are still considered the gold standard for permanently solving the problem of heavy uterine bleeding in women unconcerned with future childbearing. However, it is also the most invasive option, although the procedure can sometimes be performed laparscopically, with minimal incisions and recovery time.
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