It is sad to me how very little women actually understand about their bodies, and men, quite often, know even less. This creates intimidation and when we're intimidated, more often this leads to dismissive or even oppressive behaviors. Women have largely been taught that their cycles are a burden, that they're a huge inconvenience and even an embarrassment. They slow us down and can cripple us, even make us hysterical. We dread #menopause and in large part try to ignore all that make us uniquely female.
This also means when things are abnormal, we can disconnect, hope it goes away, or assume we're just broken in someway and so say nothing. Our cycles though are an important part of our health and wellness, a sixth vital sign, in fact. When we cycle regularly, in appropriate amounts, with little discomfort, and we're in tune with the signals of our body, this is exceedingly reassuring. When any of these are amiss, this is a signal, a message from our body that something is off balance, that we need to tune in and pay attention, make some adjustments, address a need. Unfortunately, too many aren't real aware of what is normal, so they aren't real confident when something is outside of normal. I've shared a great deal about Appreciating Your Monthly Moon and Menstrual Disorders: Understanding Moon Dysfunctions in our Wellness program for active clients, and I've written an entire program for Embracing Your Crone Years because there is so much beauty in this final transition. I've also written about Celebrating the First Moon in our Littles program for our active pediatric clientele. Dive in if you are unfamiliar with what is normal or aren't quite in tune yet with the natural flow of your body, but here, I want to talk about what might be abnormal uterine bleeding and when you should connect with your trusted provider.
Approximately one in ten childbearing women will experience abnormal uterine bleeding, or more specifically about 9 to 14 percent (Sweet et al., 2012). Genital bleeding during childhood is very abnormal; always seek evaluation in this scenario. Bleeding after menopause, at any time after your cycle has been absent for a year, is also exceedingly abnormal so seek evaluation with your trusted provider. Heavy bleeding more consistent with hemorrhage is also outside the scope of this article, but another time urgent evaluation is most appropriate. Abnormal uterine bleeding in the childbearing woman is #bleeding that occurs at any point between adolescence through perimenopause, that is not consistent with a physiologic moon cycle.
This can really present in a number of different ways. For some women this may mean irregular or infrequent menses. It may mean really light or excessively heavy menses. It may be the absence of #menses, outside of pregnancy. It might also mean a long moon cycle, more than 35 days between your flow or flow coming sooner than every third week. It might mean a flow lasting more than seven days or light bleeding somewhere in between your menses.
Abnormal uterine bleeding also includes needing to change your menstrual products every one to two hours, passing clots greater than an inch, or "very heavy" periods. Bleeding heavy enough that your iron levels, or #ferritin levels, are low is also cause for concern, as is bleeding after intimacy.
Sixth Vital Sign
Many years ago, I was taking a nine-month course with a group of women that I met with weekly, for several hours. It was one of those scenarios where ten very different people came together and for whatever reason, in spite of their differences, we all resonated with each other exceedingly well. There was no judgment, no fear, no walls; we found a really sacred and intimate connection.
We had gathered for many months before one of our beloved shared she had been diagnosed with cancer. This took our breath away, but she didn't share many details; she was confident she would fight it. Another gal, my age, shared she had beaten brain cancer just a few years prior. She was now cancer free, but working really hard to make her health a priority. Others shared grief and great triumph. It was so incredibly humbling. We put it all out there; we inspired one another. We realized that in the midst of our own chaos, maybe even in the midst of our own shame, everyone was struggling in someway and working to do their best. We honored this in each other.
During one of our conversations, one momma who had recently had a baby shared she had the baby blues and really couldn't wrap her mind around leaving her baby and returning to work. One of our group members suggested she ask her provider for an anti-depressant, seeking validation from me, the clinician in the group. However, I don't believe depression is the same as grief. It is absolutely natural to want to be with your child, so her baby blues may be more about her needing to tune in and decide what she really wants, maybe make some big life decisions, but grief would not be something I would treat with pharmaceuticals.
This lead to a longer discussion and somehow circled back to me discussing our menses, or the monthly moon as being a very normal, natural expression of our bodies that can offer us reassurance. If this is abnormal, we need to ask why. One of the gals in our group, our friend with the ailing health questioned me, saying this didn't make sense to her because she hadn't had her period for years and it wasn't a problem; then we all realized, this message from her body had been ignored for too long. We just sat there in loving silence, deeply sorry for this missed opportunity. This grieves me so much; the realization that the female body is not regarded with the utmost of respect, worse really, it is dismissed entirely so that our suffering becomes the norm.
Please, take time to learn what is normal and what is not, what is unique to you and what may be signs that you're overlooking. Take time to tune into your body, become truly embodied and appreciate the true beauty in being female. Dive into our programs if you need direction, and teach this to your daughters so they are connected to their bodies and can nurture their health their entire lives. Another story: I once had a student nurse practitioner working with me when an Amish client called and asked me to come see her daughter right away, because her monthly bleeding had come during the day, rather than at night. My student laughed at the audacity of this call, but they knew this was indication something was wrong. Interestingly enough, we discovered Lyme disease through a detailed history and exam. They were unfamiliar with the signs and symptoms of Lyme, but they were well familiar with what a normal cycle looks like and were confident enough to call in a doctor when this fell outside the norm.
Diving in Deeper
Keep records. Journal. Track your cycles and symptoms; pay attention. When I was a newer midwife, I learned about mittleschmirz. I had never heard of this before, when a woman feels she has ovulated. It sort of made me chuckle because I thought, no way. Then I had a ping in my side and wondered. I did the math and recognized it could have been, but was probably it was just one of those weird sensations we sometimes get and never know why. They it happened again, and again I wrote it off as a coincidence because that's just too crazy, right? I was gaslighting myself. A few years of this and I could confidently say, "yeah, I just ovulated." It seemed too wild to admit aloud. It got to the point that I didn't have to use any method of child-spacing efforts because I knew exactly when I was fertile. I couldn't have been surprised if I wanted to because I was just so very in tune.
At the extremes of our reproductive years, we can experience cycles in which we aren't ovulating. After a young gal begins to menstruate, our hypothalamic-pituitary-ovarian (HPO) axis can still be a bit immature so that the hormonal feedback she needs to ovulate doesn't occur. This can happen for a few years in fact, and then all of a sudden she seems to have the worst menses, doubled over in pain. This is indication she has ovulated.
The same can occur as long as eight years prior to menopause, no #ovulation. This is more likely to be a bit more irregular, or we can sort of sputter out two eggs at a time which is why twins are more common at about 37 years of age. When we don't ovulate in these latter years, we don't have the corpus luteum to produce progesterone for us, so we have prolonged exposure to estrogen which overstimulates our endometrium and this can grow thicker, cause some instability, and potentially some erratic bleeding.
This abnormal bleeding related to lack of ovulation, or anovulation, also occurs in women with polycystic ovarian syndrome (PCOS). Uncontrolled diabetes, hypo- or hyperthyroidism, and hyperprolactinemia can also disrupt ovulation because each of this conditions disrupt our HPO axis (Sweet et al., 2012). Eating disorders and some medications, more typically medications for seizures or antipsychotics, are additional causes we consider. When we aren't ovulating and our hormones are out of balance to that our endometrium is still stimulated, we risk endometrial cancer. While this is rare in adolescence, it does happen and should be considered when there has been anovulatory cycles for two or three years, or with morbid obesity. About 14 percent of perimenopausal women with recurrent anovulatory cycles develop endometrial cancer or its precursor, hyperplasia with atypia.
What if? What happens?
If you are young and have two or three years with irregular cycles, or consistently have more than three months between cycles, or any women who we suspect are not regularly ovulating, especially those who are peri-menopausal and having increased bleeding whether in duration, volume, or frequency, spotting in between your cycles, or bleeding after menses, then it's time to connect with your women's healthcare specialist. We will talk about your history, get a better understanding of your normal, your overall health, your family history and we will evaluate for the potential for polycystic ovarian syndrome. We will consider your weight, your relationships, your stress, and the potential for pregnancy. We will also evaluate your thyroid and prolactin levels.
We will discuss the option of having an ultrasound to measure your endometrium, and potentially an endometrial tissue biopsy, which would be referred to a #gynecologist. This isn't always the route we take, especially initially, depending on your history and exam. If you are young though and have had prolonged exposure to estrogen stimulation, this may be wise. If older than 35 years and we suspect anovulation bleeding or if there has not been response to therapy, then again, further evaluation may be beneficial.
The ultrasound, often transvaginal, detects uterine tumors, polyps, endometrial and myometrial abnormalities, and can evaluate your ovaries. Sometimes a saline infusion is added to help improve diagnostic ability, but there is some limited availability and more often gynecologists will offer a scope into the uterine cavity within their office. This gives them direct visualization of the uterine cavity and even allow for direct biopsy during the procedure. These are more expensive than the ultrasound, and they don't evaluate the myometrium or the ovaries, but they are quite sensitive and specific for diagnosing abnormality within the cavity of the uterus.
Treatment guidelines are diverse. There are pharmacologic options and surgical options. The American College of Obstetrics and Gynecologists recommends treatment with combination oral contraceptives or cyclic progestin to induce routine withdrawal bleeding and decrease the risk of hyperplasia or cancer. Keep in mind, this is not a normal, physiologic menses or cycle, but rather, hormones to prevent cycling which is then paused so there is some withdrawal bleeding. Provera is often utilized, at 10mg per day for 10 t- 14 days per month. Megace is also common, at 40mg a day, for those who have benign hyperplasia or inserting the IUD, Mirena. A endometrial biopsy is then repeated in three-to-six months to assure there is response to treatment. If hyperplasia progresses with some atypical cells, particularly with treatment, then hysterectomy is recommended.
Natural, functional and integrative approaches are addressed in our Wellness program, free for our active clients. Our Earth Medicine program also has a number of resources for utilizing botanicals to nudge the body into a better state of health.
Ovulating but Still Some Abnormality? What Then?
We do tend to group women who present with abnormal uterine bleeding into those who are ovulating and those who are not, because the underlying pathology is a bit different. When they are ovulating and have normal, regular intervals between menses, but there is excessive volume or duration, then we think hypothyroidism, late stage liver disease, and bleeding disorders. They may also have structural changes, such as fibroids or endometrial polyps. Von Willebrand disease (vWD) is the most common heritable bleeding disorder, and is present in about 13 percent of women who heavy cycles, more likely even in young gals who present with heavy bleeding. These women, unlike those who are not ovulating, are producing progesterone, so their are sloughing their endometrium regularly and have minimal risk of developing cancer (Sweet et al., 2012). The unfortunately reality though is about one-half of these reason, never learn why their are bleeding so heavy.
Again, we would want to evaluate for pregnancy, evaluate her blood count, and evaluate the thyroid. In young gals, we would evaluate for vWD, and in women with a family history, if they bleeding longer than seven days, or if they experience flooding or are unable to engage in their daily activities as they normally would. If they have a history of anemia or excess bleeding with tooth extraction, delivery or miscarriage, or surgery, we would also want to evaluate for vWD. Initial testing would include the complete blood count, because here we can evaluate for anemia, leukemia, and thrombocytopenia. A prothrombin and activated partial thromboplastin time can help us evaluate for factor deficiencies which can lead to abnormal bleeding. We'd want to specifically test for vWB, if epigenetic testing has not already been done, and collaborate with a hematologist based on findings.
Not common in adolescents, but certainly can happen, is a finding of uterine polyps and fibroids. Transvaginal ultrasound would identify this, as well as evaluate the ovaries, uterus, and endometrium. Saline infusion can assist in this evaluation, but not so commonly done. Ultrasounds are helpful but not as sensitive or specific as one might assume, so you aren't going to get an absolute answer here. If you still have concerns after a reassuring ultrasound, keep digging in and keep in mind, the skill of the ultrasonographer can make all the difference. Biopsy may prove necessary or direct visualization of the endometrium with #hysteroscopy.
What Now? Can I Get Help Even if My Risk Isn't Cancer?
Women so often report that they aren't listened to or their symptoms are dismissed. When we've ruled out the risk for cancer, women's concerns can easily go ignored or be under appreciated because there is some complexity here that requires clever thinking and admittedly, not every clinician has the time or the patience. The goals of treatment for women who have heavy periods, but are ovulating, and they don't have a bleeding disorder, is largely about reducing the risk of anemia. They are typically offered hormones, progestins specifically, and the IUD can be very effective in this regard. Satisfaction is similar to that of ablation and even hysterectomy, at a much lower risk and cost (Sweet et al., 2012).
Women who want to avoid hormonal therapies are often recommended non-steroidal anti-inflammatory drugs (NSAIDs), because these decrease prostaglandin levels which reduces menstrual bleeding. Anaprox and Ponstel have been found to decrease flow volume by 46 and 47 percent, which is significant. Orgasm, whether in an intimate relationship or self-derived, have also been found to shorten the menses by at least a day. Lysteda is another option, an anti-fibrinolytic that prevents activation of plasminogen so decreases bleeding significantly more than the NSAIDs, can be offered in two 650mg tablets, three times a day for the first five days of the cycle (Sweet et al., 2012). This has been a more expensive approach though, so reserved for those who desire fertility or who can't take contraceptives.
If polyps and fibroids are an issue, these are removed most often, or treated with uterine artery embolization, depending on desire for future pregnancy. If treatment otherwise is not responsive, then a uterine ablation may be offered which essentially destroys the endometrium and is considered permanent, so not advised in those potentially desiring pregnancy into the future. About one-third of women require a repeat procedure in about five years. Hysterectomy may be offered, but these do have more adverse effects and a longer recovery time, as well as higher cost than procedures that spare the uterus. Hysterectomy is also associated with ovarian failure about four years sooner than expected (Sweet et al., 2012).
Again, Natural, functional and integrative approaches are addressed in our Wellness program, free for our active clients. Our Earth Medicine program also has a number of resources for utilizing botanicals to nudge the body into a better state of health.
References
Sweet, M. G., Schmidt-dalton, T. A., & Weiss, P. M. (2012). Evaluation and management of abnormal uterine bleeding in premenopausal women. American Family Physicians, 85(1), 35-43.
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