Period Changes

Dr. Robin Noble is a NAMS certified ob-gyn. Let’s Talk Menopause spoke to her recently about period changes, often one of the first signs of perimenopause.

Changes in your period are often the first sign of perimenopause. Why?

Due to the flux in hormones, the ovaries may no longer predictably ovulate during perimenopause. A woman may notice changes in her bleeding and wonder, ‘Could this be perimenopause?’ Absolutely. ‘Could this be something else?’ Absolutely.  While we cannot predict what pattern of bleeding changes someone will have while going through perimenopause, we can say that these changes are often a normal part of the menopausal transition. Perimenopause can bring about changes in bleeding but not all changes in bleeding are caused by perimenopause. 

What are the bleeding changes associated with perimenopause?

These changes are incredibly variable. Some people will continue to have perfectly predictable, regular periods up until they experience a full year without any bleeding—the definition of menopause. Others will notice changes in the frequency, flow, and duration of their periods. Some may skip periods entirely, sometimes for months, and then the bleeding returns. Some people in perimenopause may have ‘loop cycles’—one cycle almost on top of another. These loop cycles can result in bleeding two weeks after what seemed to be a normal cycle, followed by a six week hiatus before another bleeding episode. For many, the bleeding comes in fits and starts, a little bit like during adolescence when the ovaries were not as predictably regulated. 

Others experience menorrhagia: notably heavier or prolonged bleeding. Normal menstrual periods are a good barometer of overall health so when periods become abnormal it may be a clue that something else is going on. It is a good idea to not automatically assume it’s perimenopause, as heavy bleeding can be caused by other things such as polyps, fibroids, adenomyosis, thyroid dysfunction,  endometrial hyperplasia, or endometrial cancer.

Can you tell us more about fibroids and heavy bleeding?

Uterine fibroids are noncancerous growths that can occur in the smooth muscle of the uterus. Nearly 50% of women have them and, most of the time, they don’t require intervention at all. It depends where the fibroids are located (within the cavity, within the wall, or bulging from the wall), how big they are, and ultimately what symptoms they produce. Some fibroids may cause pelvic pressure, urinary frequency, low back pain, and heavier bleeding. Sometimes, fibroids can be detected during a pelvic exam, but a pelvic ultrasound is the best way to identify and characterize fibroids.

Should women consult with their doctors about period changes?

Before I answer that, I want to note that a lot of people don’t like to see their doctors. They put it off, or feel their symptoms aren’t serious enough to warrant an appointment. Some people are skeptical of doctors, or feel they won’t be heard. Changes in bleeding, especially heavy bleeding, can be a bit frightening and it can lead to anemia. It’s important for people to see a doctor, or another trusted healthcare provider, if they are experiencing concerning symptoms.

Many women aren’t sure whether to see a primary care doctor or an ob-gyn. Perimenopause, the years prior to menopause, can be challenging for many women as the associated hormonal changes can cause many symptoms. This is often a good time to seek speciality care with a gynecologist or women’s health care provider. It’s important to talk with an expert who can give you anticipatory guidance—a sense of what to expect as one progresses through perimenopause, reaches menopause, and then becomes postmenopausal. An ob-gyn can let you know what’s normal and what may not be normal. People experiencing perimenopausal symptoms should know that there are treatment options to alleviate symptoms and suffering – women need to know that physical suffering and changes in mood need not be an inherant, unavoidable part of the menopause transition. 

What are some treatment options for abnormal bleeding? 

There are many. It can begin with something as simple as the use of over-the-counter medications such as ibuprofen or naproxen, if taken properly. The secret is to medicate before the onset of bleeding and cramping as these drugs don’t work as well if taken later. If women remember to premedicate with these non steroidal anti-inflammatory drugs, bleeding can be reduced by 50%.

Hormonal options can improve the symptoms of perimenopause and reduce bleeding. Combination oral contraceptives, progesterone only pills, injectable medications and a whole host of newer hormonal options (GnRH antagonists in combination with estradiol and norethindrone) can also be effective in controlling bleeding symptoms.

A levonorgestrel IUD (intrauterine device) can be a great option that provides contraception as well as bleeding control. Originally designed as birth control, these IUDs reduce or eliminate heavy bleeding. The device is placed inside the uterus—an office procedure that takes roughly five minutes to complete and is reversible at any point. These IUDs are effective for up to seven years and result in approximately a 90% reduction in the bleeding; moreover the 52mg levonorgestrel IUD decreases the risk of endometrial cancer and has very few side effects. People who were once soaking through a pad or tampon every hour may experience only very light staining after a few months. Some people will have no bleeding at all. 

Another option is tranexamic acid (tXA). This helps your blood to clot and stop heavy bleeding. It creates clotting at the level of bleeding and is used to reduce  heavy periods. 

In the past, heavy uterine bleeding was often treated with a hysterectomy. Sometimes surgery is necessary or preferred, but we have many less invasive options available now. A hysteroscopy is a minimally invasive surgery that allows a gynecologist to visualize the uterine cavity and address intracavitary pathology-polyps and submucous fibroids. A uterine ablation is a minimally invasive procedure that can be done in an office or ambulatory surgery center that destroys/damages the endometrium (uterine lining) in a controlled way, to reduce the menstrual bleeding.

All of these options should be discussed with a trusted healthcare provider-as they have some particular risks and benefits and potential complications. Some options may be particularly well suited to a clinical scenario, and others may be contraindicated for particular patients (for example, combination oral contraceptives should not be used by smokers over the age of 35). Treatment should be individualized to a person’s symptoms, goals and risk factors. With many options to choose from, as a partnership, doctors and patients can usually arrive at a really good management decision. Sometimes evaluation and reassurance is all that is needed and we can monitor symptoms. At times, the first option is not satisfactory for any number of reasons and we move on to another option. There is no need to put up with heavy bleeding that is interfering with your life and activities when there are so many treatment options available.

Dr. Robin Noble, Ob-gyn  

Dr. Noble, a board certified ob-gyn, completed her undergraduate work at Yale, her medical training at Columbia, and her residency and fellowship at Yale. She now focuses on gynecologic care in Portland, ME, specializing in the menopausal transition, infertility, fibroids, pelvic pain, sexual function, aging, preventative care, and positive health habits. 

She completed post graduate certificates from the Surgical Leadership Program at Harvard Medical School and the Physician Executive Leadership Institute at the Daniel Hanley Center. Dr. Noble is a certified menopause provider through the North American Menopause Society (NAMS) and she is board certified in Lifestyle Medicine.