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Heavy or prolonged menstrual bleeding is a common experience for about 33% of people who are in transition to menopause.
Episodes of excessive flow often meet the criteria of abnormal uterine bleeding, a medical condition defined by vaginal bleeding within a six-month period that is excessive in amount, duration or frequency during or between menstrual periods.
Despite the prevalence of excessive bleeding and its impact on quality of life, scant research exists on whether this bleeding is also associated with other typical menopausal symptoms, according to the authors of a new study.
Having experienced three or more episodes of heavy or prolonged menstrual bleeding within a six-month period is associated with symptoms of fatigue, according to the report published Wednesday in the journal Menopause.
To the authors’ knowledge, the study is the first to evaluate over time the association between heavy and prolonged menstrual bleeding among premenopausal and perimenopausal women and their reports of fatigue or vitality.
“Menstruation remains a subject cloaked in silence and associated with taboos, even within the realm of scientific inquiry,” said lead study author Dr. Siobán Harlow, professor emeritus of epidemiology and of obstetrics and gynecology at the University of Michigan, via email. “Lack of dialogue about menstruation, particularly about the changes in bleeding patterns as women approach menopause, leads to women’s lack of knowledge about what is normal.
“Hopefully these findings will encourage further evaluation of potential associations between menstrual bleeding and other symptoms of menopause such as disrupted sleep and cognitive fog,” Harlow added.
Perimenopause typically occurs about three to 10 years before menopause, a day that marks one year without menstruation and signals the end of a woman’s reproductive life. The transitional period is prompted when the ovaries gradually stop working, according to Johns Hopkins Medicine. During this time, levels of the hormones estrogen and progesterone can fluctuate, leading to mood swings, irregular menstrual cycles and other symptoms such as depression.
The authors reviewed the health data of 2,329 women who were age 47 on average when they enrolled in the Study of Women’s Health Across the Nation in 1996 or 1997. At the beginning and at each annual follow-up visit for up to 10 years, the women had answered questionnaires about their gynecological, menstrual and medical histories.
Participants also kept a monthly menstrual calendar in which they noted their menstrual bleeding until two years after their final menstrual period or for up to 10 years. Reporting “very heavy bleeding” meant they had to change a sanitary product every hour or two for more than four hours during the day. The authors defined prolonged menstrual bleeding as bleeding that lasted more than eight days, whereas heavy menstrual bleeding meant very heavy bleeding for three or more days, according to the study.
At the first six visits and the eighth visit, the team gauged participants’ sense of vitality or fatigue by asking them four questions from Rand’s 36-item Short Form Health Survey: In the past four weeks, for how much time had they felt full of pep, full of energy, worn out or tired?
Women who experienced at least three episodes of heavy menstrual bleeding in the prior six months were 62% more likely to feel tired and 44% more likely to feel worn out, according to the study. Having reported three or more instances of prolonged bleeding within the past six months was linked with 32% lower odds of feeling full of pep.
“It seems like it would be intuitive that heavy menstrual bleeding is associated with fatigue symptoms,” said Dr. Stephanie Faubion, medical director of The Menopause Society, who wasn’t involved in the study. “What’s surprising is we’ve never actually looked at this before, and I agree with (the authors) at the end, where they say one of our most commonly used menopause questionnaires doesn’t even ask about bleeding.”
“Menopause questionnaires are not designed to cover perimenopause because, by definition, if you’re menopausal, you don’t bleed anymore,” said Faubion, who is also the Penny and Bill George Director of the Mayo Clinic’s Center for Women’s Health. “Perimenopause is just kind of an understudied, underdescribed time.”
With half the world’s population experiencing menopause if they live to midlife, far more studies on this stage are needed, said Dr. Leana Wen, an emergency physician and adjunct associate professor of emergency medicine at George Washington University in Washington, DC.
The link between fatigue and abnormal bleeding
The association between heavy and prolonged menstrual bleeding and fatigue could be due to iron deficiency and iron deficiency anemia caused by blood loss, which are well-established causes of fatigue in general and are known complications of abnormal uterine bleeding, the authors said — an idea supported by a small August 2016 study of Black women.
Anemia is a condition of not having enough red blood cells or hemoglobin (an iron-rich protein within blood cells that binds to oxygen) to carry oxygen throughout the body. Several common causes include iron deficiency, deficiency of other vitamins required for the production of red blood cells, and when bleeding causes loss of red blood cells and hemoglobin faster than they can be replaced.
However, the authors didn’t have measures of participants’ blood iron, which would have helped them make a stronger case for a link.
Accordingly, Faubion isn’t sure that anemia is the only potential culprit, especially “because it takes a lot of bleeding to become anemic.”
“That’s an easy explanation, but is it also tied with (whether people) are not sleeping as well because they’re getting up because they’re going to the bathroom and they’re bleeding everywhere?” Faubion said. “Another thing is, if you’re iron deficient — which people can be iron deficient without being anemic — you can get restless legs syndrome, which can disturb your sleep.”
Harlow, the lead study author, agreed but added that the team did control for reported sleep problems.
The study still suggests that when evaluating patients’ complaints about fatigue, health professionals should ask them about abnormal menstrual bleeding and test for low iron and anemia, the authors wrote. Initial screening for prolonged and heavy menstrual bleeding during the menopause transition, even before potential reports of fatigue, should also be considered, Wen said.
“Those going through menopause should document their cycle length, duration of menstrual bleeding, and whether it is perceived as being heavier than before,” Wen said.
If anemia is what’s causing someone’s menopausal fatigue, health providers need to stop the bleeding and replace the iron, typically with oral prescription-strength iron to start, Faubion said. Increasing iron levels is what helps someone make more red blood cells and rebuild their blood supply.
Common treatments for excessive menstrual bleeding include non-steroidal anti-inflammatory medications, or NSAIDs, such as naproxen or ibuprofen, and birth control pills, which can reduce bleeding by about 30%, Faubion added. Hormonal intrauterine devices can stem bleeding by anywhere from 79% to 98%. Restless leg syndrome can also be addressed, often by correcting an iron deficiency, Faubion said.
“Abnormal uterine bleeding should never go unevaluated,” Faubion said, “and it needs somebody to sort it out. Because the thing that we’re risking missing is not only anemia, which can cause fatigue, but it can also be an early warning sign of a cancer.”
