Hormonal Contraception

Midlife Muddle - Own the Power of Naming

Bonnie — Fri, 25 May 2012 11:01:32 -0500

This article originally appeared as post on the Society for Menstrual Cycle Research re:Cycling blog.

By "midlife muddle" I don't mean the trouble concentrating or remembering names that sometimes occurs for all of us (but more frequently if we've wakened with night sweats and not gotten back to sleep). I mean the condoned and official confusion about naming of women's reproductive aging. Let me show you why I am upset.

STRAW+10 staging system for reproductive aging in women
Stages of Reproductive Aging Workshop (STRAW) held a 10-year anniversary last summer. (As someone frustrated by not being "heard" at the original conference, I still think that the "W" in STRAW should stand for Women!) Despite that, STRAW+10 has made progress because at least some of the classification is now supported by population-based prospective data rather than based on what experts believe. The names that are now politically correct are summarized in the STRAW+10 Executive Summary¹ and the diagram¹ at right.

We in the Society for Menstrual Cycle Research have also had our say about nomenclature: "Naming Women's Midlife Reproductive Transition". I wrote this (with revision and refinement by collective effort of SMCR members) because women keep getting left out of this naming business. For example:

•a regularly menstruating woman with night sweats, heavy flow, and increased cramps could learn to call herself perimenopausal² (not STRAW+10 Late Reproductive Phase -3b?!).
•a woman who just finished her period can say, I'm in late perimenopause and have at least a year without further flow before I'll be menopausal. Based on STRAW+10 she could be told that specific menstruation was her final menstrual period (nickname "FMP") and the next day, according to STRAW+10 be told that she is now "postmenopausal"!!
•a woman with sore breasts, irregular periods, and heavy flow could say, I'm in perimenopause. However, she may instead be told she is in the "Early Menopausal Transition." Because she has heavy flow she is also likely to be prescribed the birth control pill (as is currently and commonly recommended). Usually she will not be told that The Pill will make her perimenopausal irregular flow worse-she may well start spotting in the middle of her cycle.³
This new and improved STRAW+10 still centers all of women's reproduction on that mythical FMP. But to call the FMP "menopause", as many women's health experts do, is just unscientific. It takes at least a year without another menstruation in those of us over age 45 before nine out of ten of us will not get another period4. But one (out of ten) of us will get a further, normal period even though we've been that whole year without any⁴. We can tell that new flow is normal (in other words, does not need investigation for endometrial cancer) if we had cramps or bloating or sore breasts or moodiness-or all of these-that told us our period was coming.

So our new Naming position statement says don't call it "menopause" until you've not had a period for a year. And do call it "perimenopause" if things are variable and changing even if you are still having regular flow².
Three of nine changes can confirm for you that you are perimenopausal even if your flow is still regular:²

1.Shorter cycles (25 days or less);
2.Increased cramps;
3.Heavier flow;
4.Increased trouble sleeping-especially waking up in the middle of sleep;
5.New or increased migraine headaches;
6.Night sweats-especially if they tend to occur before or during flow;
7.An increase in or new premenstrual mood swings;
8.New sore, enlarging or nodular breasts; and
9.Weight gain without changes in what you eat or the exercise you do.

If women can learn to call themselves perimenopausal, they will be saying they know that perimenopause is not the same as menopause-perimenopause is a midlife transition with higher and erratic estrogen levels. Menopause is a fairly stable life phase with normally low estrogen and progesterone levels that begins one year after their last menstrual flow.

Furthermore, by naming themselves accurately they will be able to tell whether a medication that is proposed for them has been tested and proven effective in perimenopausal women. Usually symptomatic women are treated with oral contraceptives (that are proven reasonably safe and useful for premenopausal contraception), or offered hormone therapy that has only been tested and shown effective for hot flushes/flashes in menopausal women.

So. . . I like the word perimenopause and think if women understand and own it they will be on their way out of a midlife muddle.

References

1.Harlow, S. Executive Summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging [pdf]. Fertility Sterility, 2012 doi: 10.1016/j.fertnstert.20012.01.128

2.Prior JC. Clearing confusion about perimenopause. BC Med J 2005; 47(10):534-538.

3.Casper RF, Dodin S, Reid RL, Study Investigators. The effect of 20 ug ethinyl estradiol/1 mg norethindrone acetate (MinestrinTM), a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause 1997; 4:139-147.

4.Wallace RB, Sherman BM, Bean JA, Treloar AE, Schlabaugh L. Probability of menopause with increasing duration of amenorrhea in middle-aged women. Am J Obstet Gynecol 1979; 135(8):1021-1024.

Blood Clots and the Birth Control Patch

Elyse — Mon, 08 Dec 2008 12:20:54 -0600

Emergency Contraception is now available over-the-counter!

Elyse — Tue, 03 Jun 2008 13:35:30 -0500

Why am I no longer interested?

Elyse — Fri, 08 Feb 2008 19:54:08 -0600

Spotting Before Periods

Elyse — Tue, 04 Dec 2007 17:08:10 -0600

Choices for Effective Contraception in 2006

Elyse — Thu, 08 Nov 2007 18:16:08 -0600

One of the remarkable advances for women in the last 50 years has been the development, scientific testing and availability of effective hormonal contraception methods such as oral contraceptives (the Pill). Given CeMCOR's goal to see each woman attain healthy ovulation and regular menstrual cycles as well as to control her own fertility, we believe that hormonal contraception, especially the Pill, should only be used for birth control. In weighing choices, contraception methods should pose no greater risks than those associated with (unwanted) pregnancy.

Hormonal contraceptives have become safer in recent years as their estrogen doses have decreased, as new progestins not from male hormones have been developed, and with the recent availability of hormonal contraception in the form of a vaginal ring or a skin patch. These last non-Pill kinds of contraceptives have had little press, but probably much safer. That is because their high estrogen levels are delivered, not through the mouth to the liver and then into the blood stream, but through the skin or vagina and directly into the blood stream. That is important because pill forms of estrogen cause the liver to make higher levels of blood clotting factors—the higher the clotting factors the greater the risk for blood clots (thrombophlebitis and pulmonary embolism) (1).

Pill forms of estrogen (whether in Pill or in menopausal ovarian hormone therapy) cause increased risks for blood becoming thicker and making a blockage or clots in the blood stream (1). These blood clots can go to the lungs (pulmonary embolism) and cause a life threatening problem and also to avoidable risks for diseases like strokes and heart attacks. Just like I will no longer recommend pill forms of estrogen, even bio-identical estrogen, for women who need it for menopause , I strongly suggest that the vaginal ring or patch form of hormonal contraception be used, if at all possible, instead of the Pill.

My primary contraceptive recommendation, however, is not hormone-changing methods. It is a combination of a physical barrier to sperm plus a local vaginal spermicide. Barrier methods include diaphragms, condoms, female condoms and cervical caps. Local vaginal contraceptives are available as jelly or foam. This barrier-plus-vaginal-spermicide method, if used every time, is as effective as hormonal contraception and poses no health risks. Furthermore, given that barrier methods decrease the risks for sexually transmitted infections (such as HIV, hepatitis, gonorrhea, syphilis and others), this non-hormonal method makes even more sense. Of barrier choices, my own preference is for the diaphragm because a woman controls its use and can put it in place ahead of time. Most local Planned Parenthood clinics or Community Health Centres can provide birth control information and fit diaphragms.

How does the Pill work?

Hormonal contraception, to be successful, must disrupt the normal reproductive system at one or more of its important parts: hypothalamus and pituitary (in the brain), ovary, uterus and cervix. Current pills rely on high dose estrogen to suppress the brain's stimulation of the ovary and on a progestin to make the endometrial lining of the uterus thin and dry out the cervical mucus. Although we call the hormones in the current Pills “low dose,” that's compared with the first super-high dose pills from the 1960s. To be effective at preventing pregnancy, the doses of estrogen and progestin in the Pill have to be high enough to (usually) suppress the brain, pituitary and ovary production of hormones. Compared to average estrogen and progesterone levels during the normal menstrual cycle, current Pills, the patch and the vaginal ring cause about four times higher estrogen effects and about the same synthetic progestin effects as ovulatory menstrual cycle progesterone.

The Pill, compared with the patch or vaginal contraceptives, appears to give a different pattern of estrogen levels. In general, the Pill, taken once a day, gives a high level of estrogen for part of the day, but average levels are lower. In contrast, the patch and vaginal ring contraceptives don't produce a high peak estrogen level but may produce higher average estrogen levels. Recently the contraceptive patch in the USA was served with an FDA warning because it released an average amount of estrogen that was higher than current Pill levels. However, the Canadian form of the same patch has an importantly lower dose of estrogen (0.6 versus 0.75 µg ethinyl estradiol). With this lower dose patch, average ethinyl estradiol levels are similar to the Pill (2).

For reasons of tradition, and because the previous Pill progestins were all derived from male hormones and had negative effects on cholesterol, the amount of progestin in the modern Pill is controlled to be relatively less high than estrogen. Progestins, like estrogen, produce contraception through suppressing the brain control of reproduction, but they also make the uterine lining too thin for a fertilized egg to hold on and grow, and make the cervix dry. Estrogen, especially in high levels like at the midcycle peak in the normal menstrual cycle, causes the cervix glands to make slippery clear mucus that helps sperm swim upward to fertilize an egg. Progesterone and progestins inhibit the actions of estrogen on cervical mucus. Therefore, there are successful forms of contraception that contain only a progestin, including a daily low-dose (0.35 mg) norethindrone pill (so called “mini-Pill”), the safest of two morning-after emergency contraception methods (called “Plan B”), a progestin-only injection with medroxyprogesterone and a levonorgestrel-releasing IUD. There is no estrogen-only hormonal form of contraception because it would cause endometrial cancer.

The Pill suppresses the brain control of reproduction, therefore we think of it as preventing our own ovaries from making hormones. However, a few small follicles (that each hold an egg and make estrogen) develop continuously within our ovaries, starting before our first period and continuing without regard to hormone levels until menopause (3). Usually the Pill prevents ovulation (release of an egg by the ovary), however, recent research shows that on the Pill (4) and patch (5) follicles do continue to develop and do also make some estrogen. Most follicle growth and estrogen production appears to occur during the week off hormones in the typical 28-day cycle contraception method. Importantly, estrogen amounts made by women's own bodies while taking the Pill are greater in overweight women with a body mass index (BMI, weight divided by height squared) greater than or equal to 25 compared with those under 25 (normal weight) (4).

Are there serious risks from use of the Pill?

Although we think of the Pill as safe, a 25-year study in over 45,000 British women, of whom half were on the Pill and half weren't, showed that deaths from cancer of the cervix (mouth of the uterus) and from cardiovascular diseases (like blood clots, strokes and heart attacks) were significantly increased in women on the Pill (6). That study started when Pill hormones were about 5 times higher than they are today—at its end, Pill hormones were similar to current doses. The overall death rate was similar between those on and not on the Pill, although causing cervical cancer and heart/stroke deaths, because it prevented deaths from ovarian cancer (6). A recent careful combination of all studies since 1980 of cardiovascular and blood vessel diseases during current normal-cycle Pill use showed that even the lowest dose Pills cause a doubling of the (low at that age) risk for strokes and heart attack (Baillargeon 2005). A case-control study of young women ages 18-49 with a heart attack (called cases) compared with matched women from the general population (called controls) has shown that even the lowest estrogen dose Pills still increase the risk for strokes. Heart attacks tend to be less in users of Pills with progestins not derived from male hormones (7).

To put the health risks from Pill use into practical guidelines, these are some recommendations. Those considering use of the Pill should absolutely not take it if you have a family or personal history of abnormal blood clotting or thrombophlebitis, are actively ill with hepatitis or mononucleosis (viral disease of the liver that estrogen treatment could worsen), have had breast or endometrial cancer, or are allergic to the hormones in the Pill. Pill use carries increased risks if you have a family history of breast cancer, are overweight (BMI over 25), currently smoke, have migraine headaches or have anovulatory androgen excess (sometimes called PCOS — see “Help for Anovulatory Androgen Excess (AAE) — Challenge PCOS!”). All women should have a normal pelvic examination and Pap test before starting the Pill.

What about teenagers' use of hormonal contraception?

The ovulatory menstrual cycle takes many years to become established (8) even though regular periods commonly develop within a year or so of the first period (9). Because all forms of hormonal contraception are designed to disturb the brain control of ovulation, and this system needs to grow up in teenagers, we have concerns about anything disrupting that delicate and important process. Also current “low-dose” Pills are very likely to fail as contraception if one or more Pills are missed. Injection forms of medroxyprogesterone are also not recommended (see “Depo Provera and Osteoporosis”). In addition, recent information is confirming an earlier study showing that young women using the Pill don't gain bone normally (10).

Sexually active teenagers, however, need effective contraception. The health risks for pregnant teenagers, for teenaged mothers and for their babies are higher than average. Also, the potential for life-disruption from an unwanted pregnancy is great for teenaged women who are still developing the skills they need for independent adulthood. For all of these reasons the preferred contraception is the barrier-plus-vaginal-spermicide method described earlier. That should be possible, effective and safe for conscientious teenagers especially with easily available, over-the-counter emergency contraception (11) as backup.

What about use of the Pill in perimenopause?

If the usual Pill doesn't entirely suppress ovarian hormone production, and estrogen production is even higher in overweight women, theoretically using the Pill in perimenopause would carry both greater risks for contraceptive failure and very high estrogen levels. There are potentially important differences between taking the Pill as a young woman and taking it as a perimenopausal woman. We know that estrogen levels rise in perimenopausal women because the normal brain-ovary feedback loops are disrupted with ovarian aging (12) (see “Perimenopause: The Ovary's Frustrating Grand Finale”). We also know that weight tends to increase in perimenopause. We believe that both this abnormal perimenopausal feedback and the weight gain of perimenopause are reasons to avoid use Pill use for contraception during this time. The risks for clots, strokes and heart attacks also increase with age in women and these risks are probably doubled by current use of cigarettes. Therefore, any current smoker should avoid the use of the Pill.

Sometimes the Pill is recommended in perimenopause for contraception, control of bone loss and treatment of hot flushes. To our knowledge there is only one randomized double blind controlled trial of the Pill for treatment of heavy bleeding and it showed the Pill didn't decrease flow until it had been taken for four months (13). This Pill also didn't significantly control hot flushes or improve quality of life compared a placebo (13). However, the Pill may help prevent bone loss in perimenopausal women in Phases C, D, and E (see “Could I be in Perimenopause?”) who are having irregular or skipped periods (14) based on not very scientific (not randomized or placebo-controlled) evidence.

What about the Pill and safety for bones and osteoporosis?

We know that estrogen or estrogen with progestin therapy in menopausal women increases bone mineral density (a good thing) and prevents fractures (15). We have thought that the Pill would also prevent osteoporosis. And there are some studies, usually small, in older women and without good controls suggesting that is true. However, a random sample of about 550 premenopausal Canadian women ages 25-45 showed that those who had ever used the Pill had lower bone density levels than did women who had never used the Pill (16). An earlier study showed that young women using the Pill didn't gain bone density normally compared with women not on the Pill (10). Recently a controlled study showed that negative effect of the Pill for young women's bones could be prevented by eating more calcium-rich foods (17). There is a need for more controlled studies of bone density changes, especially in young women, on the Pill.

What about continuous use of the Pill, patch or vaginal ring to stop menstruation?

There is increasing interest in elimination of periods with continuous or long cycle (say 84 days of Pills and 7 days without) rather than the classical 21-out-of-28-day use of the Pill (18), contraceptive patch or vaginal ring. I believe the following, as quoted in a MacLean's Magazine article on December 12th, 2005: “Menstruation, this amazingly intricate, carefully crafted cycle, is a vital sign of our health. To wantonly disrupt it is a horrifying thought.” We are currently preparing a full article about long-cycle and continuous contraception.

In summary, effective hormonal contraception, especially the Pill, provided a marvelous advance for women in the last several decades. Recently both patch and vaginal ring contraceptives have become available—these decrease the risks for blood clots (and other vascular diseases) that are related to the Pill. There are still many concerns such as use of the Pill in teenagers, perimenopausal women, overweight women and those who smoke. I believe it is a better choice, given the availability of effective, safe options (such as barrier-plus-vaginal-spermicide contraception) to use these rather than hormonal contraception. Hormonal contraception requires high doses of synthetic hormones and disrupts our own important menstrual cycle and ovulation.

Reference List

Scarabin PY, Oger E, Plu-Bureau. Differential association of oral and transdermal oestrogen-replacement therapy with venous thromboembolism risk. Lancet 2003;362(9382):428-32.
The EVRA (ethinyl estraiol/norelgestromin) contraceptive patch: estrogen exposure concerns. CMA Media Inc 174. 1-17-2006. Ref Type: Electronic Citation
Block E. Quantitative morphological investigations of the follicular system in women. Variations in different ages. Acta Anat. 1952;14:108-23.
Schlaff WD, Lynch AM, Hughes HD, Cedars MI, Smith DL. Manipulation of the pill-free interval in oral contraceptive pill users: the effect on follicular suppression. Am.J.Obstet.Gynecol. 2004;190(4):943-51.
Pierson RA, Archer DF, Moreau M, Shangold GA, Fisher AC, Creasy GW. Ortho Evra()/Evra() versus oral contraceptives: follicular development and ovulation in normal cycles and after an intentional dosing error. Fertil.Steril. 2003;80(1):34-42.
Beral V, Hermon C, Kay C, Hannaford P, Darby S, Reeves G. Mortality associated with oral contraceptive use: 25 year follow up of cohort of 46,000 women from Royal College of General Practitioners' oral contraceptive study. Br.Med.J. 1999;318:96-100.
Tanis BC, van den Bosch MA, Kemmeren JM, Cats VM, Helmerhorst FM, Algra A et al. Oral contraceptives and the risk of myocardial infarction. N.Engl.J.Med. 2001;345(25):1787-93.
Vollman RF. The menstrual cycle. In: Friedman EA, editor. Major Problems in Obstetrics and Gynecology, Vol 7. 1 ed. Toronto: W.B. Saunders Company; 1977. p. 11-193.
Munster K, Schmidt L, Helm P. Length and variation in the menstrual cycle--a cross-sectional study from a Danish county. Br.J.Obstet.Gynaecol. 1992;99(5):422-9.
Polatti F, Perotti F, Filippa N, Gallina D, Nappi RE. Bone mass and long-term monophasic oral contraceptive treatment in young women. Contraception 1995;51:221-4.
Soon, J. A., Levine, M. Ensom M. H., and Fielding, D. W. Expanding access to emergency contracpetion in British Columbia. CMAJ . 2004. Ref Type: In Press
Prior JC. Perimenopause: The complex endocrinology of the menopausal transition. Endocr.Rev. 1998;19:397-428.
Casper RF, Dodin S, Reid RL, Study Investigators. The effect of 20 ug ethinyl estradiol/1 mg norethindrone acetate (MinestrinTM), a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause 1997;4:139-47.
Gambacciani M, Spinetti A, Taponeco F, Cappagli B, Piaggesi L, Fioretti P. Longitudinal evaluation of perimenopausal vertebral bone loss:effects of a low-dose oral contraceptive preparation on bone mineral density and metabolism. Obstetrics and Gynecology 1994;83(3):392-5.
Cauley JA, Robbins J, Chen Z, Cummings SR, Jackson RD, LaCroix AZ et al. Effects of estrogen plus progestin on risk of fracture and bone mineral density: the Women's Health Initiative randomized trial. JAMA 2003;290(13):1729-38.
Prior JC, Kirkland S, Joseph L, Kreiger N, Murray T.M., Hanley DA et al. Oral contraceptive agent use and bone mineral density in premenopausal women: cross-sectional, population-based data from the Canadian Multicentre Osteoporosis Study. Can.Med.Assoc.J. 2001;165:1023-9.
Teegarden D, Legowski P, Gunther CW, McCabe GP, Peacock M, Lyle RM. Dietary calcium intake protects women consuming oral contraceptives from spine and hip bone loss. J.Clin.Endocrinol.Metab 2005;90(9):5127-33.
Prior JC. Ovulatory menstrual cycles are not a problem: go with the flow! BC Endocrine Research Foundation Quarterly Newsletter 2000.

Very Heavy Menstrual Flow

Elyse — Wed, 07 Nov 2007 19:02:27 -0600

When periods are very heavy or you are experiencing “flooding” or passing big clots you have what doctors call menorrhagia. The purpose of this article is to define normal and very heavy menstrual bleeding, to explain what causes heavy flow, and to show what you yourself can do in dealing with heavy flow. This, and the article called “Managing Menorrhagia—Effective Medical Treatments” for your doctor or health care provider, are to help you avoid surgeries for heavy flow (hysterectomy and endometrial ablation) if you can.

What is the normal menstrual flow?

In a randomly selected group of premenopausal women, the most common amount of menstrual flow (measured in a laboratory from all collected tampons and pads) was about two tablespoons (30 ml) in a whole period (1;2). However the amount of flow was highly variable—it ranged from a spot to over two cups (540 ml) in one period! Women who are taller, have had children and are in perimenopause have the heaviest flow (2). The usual length of menstrual bleeding is four to six days. The usual amount of blood loss per period is 10 to 35 ml. Each soaked normal-sized tampon or pad holds a teaspoon (5ml) of blood. That means it is normal to soak one to seven normal-sized pads or tampons (“sanitary products”) in a whole period.

How is Very Heavy Flow or Menorrhagia defined?

Officially, flow of more than 80 ml (or 16 soaked sanitary products) per menstrual period is considered menorrhagia. Most women bleeding this heavily will have a low blood count (anemia) or evidence of iron deficiency (1). In practice only about a third of women have anemia, so the definition of heavy flow can be adjusted to be more like nine to 12 soaked regular-sized sanitary products in a period (2).

What causes very heavy menstrual bleeding?

This is not clear. Heavy flow is most common in the teens and in perimenopause—both are times of the lifecycle when estrogen levels tend to be higher and progesterone levels to be lower. Progesterone is made by the ovaries after ovulation. However, even though you may be having regular periods, it doesn’t mean you are ovulating! The lining of the uterus or endometrium sheds during a period. Estrogen’s job is to makes the endometrium thicker (and more likely to shed) and progesterone makes it thinner. Therefore it is likely that heavy flow is caused by too much estrogen and too little progesterone. However, this has not been well shown.

The good news is that, in a large study of pre- and perimenopausal women, heavy flow was not caused by endometrial cancer. This means that a diagnostic test for cancer called a D & C (a surgical procedure in which the endometrium is scraped off) is not necessary (3). Heavy flow was most common and occurred in 20% of women ages 40-44 (3). In women ages 40 to 50, those with heavy flow commonly also have fibroids. However higher estrogen with lower progesterone levels causes both heavy bleeding and the growth of fibroids. Fibroids are benign tumors of fibrous and muscular tissue that grow in the muscle of the uterine wall; less than 10% come close to the endometrium and are called “submucus” fibroids. Only these rare fibroids could possibly influence flow. So fibroids are rarely the real cause for heavy flow and are not a reason to treat very heavy flow any differently.

Early in perimenopause when cycles are regular, approximately 25% of women will have at least one heavy period. Perimenopausal estrogen levels are higher and progesterone levels are lower (4;5). (See Perimenopause, the Ovary’s Frustrating Grand Finale.) Progesterone levels are lower because ovulation is less consistent and short luteal phases (the portion of the normal menstrual cycle from ovulation until the day before the next flow) with fewer than 10 days of progesterone are common in perimenopause (6).

Some rare reasons for heavy flow are an inherited problem with bleeding (like hemophilia), infection or heavy bleeding from an early miscarriage

Can I figure out how much I’m bleeding?

The easiest way, knowing that one soaked, normal-sized sanitary product holds about a teaspoon of blood (= 5 ml), is to record the number you soak each day of your flow. Keeping the Menstrual Cycle Diary or Daily Perimenopause Diary is a convenient way to assess the amount and timing of flow. To accurately record the number of soaked sanitary products each day you need to recall the number you changed that were half full (let’s say three tampons and one pad) and multiply that (four X 0.5 = two) to give the number of fully soaked ones. A “maxi” or “super” tampon or pad holds about two teaspoons or 10ml of blood—therefore record each larger soaked sanitary product as a “2.” In addition, record your best judgment about the amount of flow where a “1” is spotting, “2” means normal flow, “3” is slightly heavy and “4” is very heavy with flooding and/or clots. If the number of soaked sanitary products totals 16 or more or if you are recording “4”s you have very heavy flow.

What can I do for very heavy flow?

Keep a record
Make a careful record (see Diary, above) of your flow for a cycle or two. (Note—if flow is so heavy you start to feel faint or dizzy when you stand up, that is a reason to make an emergency doctor appointment.)
Take ibuprofen
Whenever flow is heavy, start taking ibuprofen, the over-the-counter anti-prostaglandin, in a dose of one 200mg tablet every 4-6 hours while you are awake. This therapy decreases flow by 25-30% and will also help with menstrual cycle-like cramps (7).
Treat blood loss with extra fluid and salt
Any time you feel dizzy or your heart pounds when you get up from lying down it is evidence that the amount of blood volume in your system is too low. To help that, drink more and increase the salty fluids you drink such as tomato or other vegetable juices or salty broths (like bouillon). You will likely need at least four to six cups (1-1.5 litre) of extra liquid that day.
Take iron to replace what is lost with heavy bleeding
If your doctor’s appointment is delayed or you realize that you have had heavy flow for a number of cycles, start taking one over-the-counter tablet of iron (like 35 mg of ferrous gluconate) a day. You can also increase the iron you get from foods—red meat, liver, egg yolks, deep green vegetables and dried fruits like raisins and prunes are good sources of iron. Your doctor will likely measure your blood count and a test called “ferritin” which tells the amount of iron you have stored in your bone marrow. If your ferritin is low, or if you ever have had a low blood count, continue iron daily for one full year to bring iron stores to normal.

What can my doctor do to evaluate heavy flow?

After asking you questions (and looking at your Diary or calendar records of flow) your doctor should do pelvic exam. If this is very painful, a culture should be taken to rule out infection that is a rare but serious cause for heavy flow. With the speculum a doctor see that bleeding is coming from the uterus and not from somewhere else.

What laboratory tests can my doctor order to assess heavy flow?

One of the consequences of heavy flow is loss of iron that is needed for hemoglobin to carry oxygen in red blood cells—low iron levels cause anemia (low hematocrit or hemoglobin which are commonly called “a low blood count”). Ferritin which shows how much iron is stored in the bone marrow could be ordered if heavy flow has been going on for a while, if you have started iron therapy, or you eat a vegetarian diet that tends to be low in iron. Ferritin can be low (because the savings account is empty) even if the hemoglobin and hematocrit are normal (the chequing account is not yet empty). Sometimes, heavy bleeding means a miscarriage so your doctor might order a pregnancy test.

What can my doctor do to treat heavy flow?

1. Oral contraceptive pills
Although oral contraceptives are commonly used for heavy flow, they are not very effective, especially in perimenopause (8). Current “low dose” oral contraceptives contain levels of estrogen that, on average, are five times natural levels plus close to normal levels of progesterone-like medicines called progestins.

2. Progesterone or a stronger progestin therapy
Progesterone therapy makes sense because very heavy flow is associated with too much estrogen for the amount of progesterone. Progesterone’s job is to make the endometrium thin and mature—it antagonizes estrogen’s action that makes it thick and fragile. However, low doses given for two weeks or less a cycle are not effective (9). One study shows that very high doses of a strong progestin for 22 days a cycle decreased bleeding by 87%(10). I recommend starting treatment with oral micronized progesterone (Prometrium®) 300 mg at bedtime or medroxyprogesterone (10 mg) taken days 12-27 of the cycle. (See Cyclic Progesterone Therapy handout.). Always take progesterone for 16 days whenever you start it for heavy flow (even if flow starts before then). If needed, progestin can be started right away, at any time of the cycle and will slow or stop the bleeding.

Heavy bleeding is so common in perimenopause that when a woman over 40 is traveling or will be in a remote place, she should ask her doctor for a 16-day supply of 10mg medroxyprogesterone tablets to take with her.

If flow is extremely heavy or has been going on for a long time, the starting progestin dose should be double the usual dose. Like before, it needs to be taken for at least 16 days a month. That means medroxyprogesterone 10 mg both morning and evening during cycle days 12-27. If heavy flow persists, add oral micronized progesterone, Prometrium®, 300 or 400 at bedtime.

As flow gets lighter the progesterone therapy can be decreased to a normal dose and taken days 14-27 of the cycle. In perimenopause, especially in women with a history of acne and unwanted facial hair (anovulatory androgen excess) it is often necessary to treat with daily high dose progestin or progesterone therapy for three months to decrease the risk for endometrial cancer. Following that it is wise to use a cyclic treatment for days 12 through 27 of the cycle for six more months.

What other therapies can be added to progesterone if needed?

Thankfully there are two medical treatments for very heavy flow that have been shown to be both safe and effective in controlled trials. The first is the use of tranexamic acid, a medication that acts to increase the blood clotting system and decreases flow by about 50% (11). The second is a progestin-releasing IUD called “Mirena®” that decreases flow by about 85-90% (12). Both of these, studied over years, are nearly as effective as endometrial ablation, the surgical scrapping or destruction of the uterine lining, in controlled trials. Either of the emergencies therapies, tranexamic acid and Mirena®, should be used with cyclic normal dose progesterone, ibuprofen and extra salty fluid if needed.

Wrapping it up

In summary, very heavy menstrual bleeding means soaking 12 or more regular sanitary products in one period. About 25% of women in early perimenopause, some teens and a few women of other ages will experience this. At present more than 50% of North American women with very heavy flow end up with a hysterectomy. Very heavy flow can be helped by ibuprofen, extra salty things to drink, increasing dietary or supplemental iron and with high dose cyclic progesterone or medroxyprogesterone. If flow still remains heavy, tranexamic acid can be added to the cyclic progesterone. Finally, a strong progestin-releasing IUD, Mirena® has been shown to be effective for both flow and for contraception.

References

Hallberg L. Menstrual blood loss. Acta Obstet Gynecol Scand 1966; 45:320.
Cole SK Sources of variation in menstrual blood loss. J Obstet Gynaecol Br Commonw 1971; 78:933.
Allen DG. Abnormal uterine bleeding and cancer Aust N Z J Obstet Gynaecol 1990; 30:81.
Santoro N. Reproductive hormonal dynamics in the perimenopause. J Clin Endocrinol Metab 1996; 81:1495.
Prior JC. Perimenopause: Endocr Rev 1998;19:397.
Prior JC.Ovulatory changes with perimenopause. Novartis Found Sym 2002; 242:172.
Fraser IS Treatment of menorrhagia with mefenamic acid. Obstetrics and Gynecology 1983; 61:109.
Casper RF Minestrin^TM on vaginal bleeding patterns in symptomatic perimenopausal women. Menopause 1997; 4:139.
Preston JT Tranexamic acid and norethisterone in the treatment of ovulatory menorrhagia. Br J Obstet Gynaecol 1995; 102:401.
Irvine GA. Randomised trial of the levonorgestrel intrauterine system and norethisterone for menorrhagia. Br J Obstet Gynaecol 1998; 105:592.
Bonnar J Treatment of menorrhagia BMJ 1996; 313:579.
Marjoribanks J Surgery versus medical therapy for heavy menstrual bleeding. The Cochrane Database of Systemic Reviews 2003; 3:1-65.

Perimenopause and night sweats

Elyse — Tue, 06 Nov 2007 17:18:12 -0600

Depo Provera and Osteoporosis

Elyse — Tue, 06 Nov 2007 16:03:56 -0600

Is the Pill a Smart Choice for a Conscientious Young Woman?

Elyse — Mon, 05 Nov 2007 19:51:14 -0600