Does your period keep you from leaving the house?

Many middle-aged women have a health problem that can greatly affect their quality of life. During perimenopause, which are the years before menopause actually sets in, a lot of women suffer from periods that are so heavy they are afraid to leave the house.

Some women have lost their jobs over this problem; others face debilitating embarrassment when their periods soak through their clothes in public. Some women even become severely anemic, requiring hospitalization. But, while it can be a real nuisance, rest assured that it isn’t unusual and there are ways to treat it.

“It is very common in the perimenopausal transition to have heavy menstrual bleeding,” said Tara Chute, MD, Vice Chief of Obstetrics and Gynecology for Cape Cod Healthcare. “We have options that can greatly improve your quality of life.”

When Dr. Chute talks to women about excessive bleeding, she asks them the following questions:

• Is this affecting the quality of your life?
• Are you having more than one period a month?
• Are your periods lasting longer than seven to 10 days?
• Do you have really heavy bleeding where you start soaking through products within one to two hours?
• Are you noticing symptoms of anemia, like worsening fatigue or lessening libido?

Don’t Suffer in Silence

Excessive bleeding is most often caused by hormonal fluctuations, according to Dr. Chute. As the body tries to release an egg, estrogen levels rise, causing the womb lining to thicken. But women who aren’t ovulating regularly don’t always produce enough progesterone to balance out the estrogen. That results in a thicker womb lining than usual which leads to a heavier flow during the period.

But there can be other causes for excessive bleeding that Dr. Chute always rules out first. They include uterine polyps, fibroids, uterine hyperplasia (pre-cancer of the uterus), or uterine cancer.

"The goal is to ensure that there is not a process going on that is concerning by doing a history, physical exam and then correlating it with imaging if needed,” she said. “Once you make sure that's the case, then we talk about quality of life and risks and benefits of treatment versus the continued concerns with their lifestyle"

Part of the reason so many women suffer in silence is that they don’t know they have options because they aren’t actually under the care of a gynecologist. Dr. Chute has observed that a lot of women stop going to an OB/GYN when they are done having children. Some switch their gynecological care to their primary care physician. Others just don’t know they should still be seen regularly.

“There can be missed opportunities for good counseling or discussions of anticipated symptoms while women are going through this transition,” she said. “In my experience, what happens is ultimately they go through it for a long time and then present to me and we talk about it, evaluate and do something about it and we could have started that process years earlier.”

Unfortunately, excessive bleeding can last for years. Menopause is defined as when a woman has no period for a year, Dr. Chute said. It can start anytime from age 40 to age 60, with the most common age being between 51 and 52.

Treatment Options

There are several treatment options for women who have heavy menstrual bleeding, which is also referred to diagnostically as abnormal uterine bleeding. The options vary greatly based on things like age, medical co-morbidities and tobacco use.

“There are some medical management strategies, such as oral medications or alternative contraceptive methods, that can regulate menstrual cycles during this transition,” Dr. Chute said. “The Mirena IUD is independently approved for heavy menstrual bleeding. You can still get pregnant during this time so it can work on both issues – contraception and heavy periods.”

The Mirena IUD is a progesterone-only IUD that is approved for five years for heavy menstrual bleeding and up to eight years for contraception.

A very common treatment Dr. Chute recommends for heavy menstrual bleeding is the NovaSure radiofrequency ablation. It is done in an operating room with sedation. There are no incisions necessary because the cervix can be naturally dilated for the device to fit through to cauterize the lining of the uterus.

“An ablation procedure is generally an outpatient procedure that takes about 15 to 20 minutes and can radically change a woman’s life,” she said. “The recovery is very short and women, generally speaking, do very well. It’s about a 97 percent satisfaction rate in women. In my personal experience, the vast majority of women are happy and wish they had done it sooner.”

Dr. Chute never automatically recommends a hysterectomy for heavy menstrual bleeding, but there are times when it is the best option. That includes women who bleed so severely they become anemic enough to need a transfusion, and women who have not had success with medical therapies or other options. But she always discusses the benefits and risks of hysterectomy first.

“The uterus is one of the support structures for the vagina so when you remove the uterus you increase a woman’s risk of prolapse which is when the vaginal wall starts to fall out – like a hernia of the vagina,” she said.

“You just really have to put all of the pieces together for the individual patient. Treatment really has to be individualized based on the patient’s age, lifestyle, medical co-morbidities, and recovery. Recovery from a hysterectomy versus an ablation are markedly different.”