How Is Heavy Bleeding Related To Perimenopause Treated?
Watchful Waiting
Your gynecologist may offer you the option of watchful waiting and taking medication until menopause, when your signs and symptoms will resolve naturally. If you opt for watchful waiting, natural progesterone cream can ease your symptoms considerably.
If you have a pre-existing medical condition that contributed to the heavy uterine bleeding (medically called Dysfunctional Uterine Bleeding or DUB), like diabetes, obesity, or von Willebrand disease, then you are not a good candidate for surgery. Your doctor will likely recommend conservative treatment because the benefits of surgery do not outweigh the risks.
Progesterone to Stop or Start Menstruation
Progesterone blocks estrogen, and therefore, reduces or stops bleeding. The timing of the progesterone treatment depends on if you want to start regular bleeding on a predictable schedule, or stop irregular or heavy bleeding that is already underway.
If you have not had a period in a long time (amenorrhea), and not in early menopause then your doctor may offer a synthetic tablet form of progesterone (a progestin) called medroxyprogesterone acetate (Provera®) to regulate and initiate regular periods. However the side effects such as blood clots, weight gain, nausea and a general feeling of being unwell often causes women to stop treatment. These effects are not experienced with bio-identical progesterone.
Depo-Provera® injections (a higher sustained dose of medroxyprogesterone acetate) are no longer recommended for Heavy Uterine Bleeding, because it is associated with irregular bleeding, blood clots and weight gain.
In general if you are younger than 45, your doctor will offer you medication options, including:
- Natural or bio-identical progesterone cream (ProFeme®)
- Synthetic medroxyprogesterone acetate tablets (Provera®)
- Oral contraceptives with high progesterone content
- Mirena®, a progestin intrauterine device (IUD)
Your choice will depend on whether or not you desire contraception.
If your problem is that you have anovulatory cycles (are not releasing eggs), and you are over 40 and in perimenopause, then you need bio-identical progesterone supplementation to correct the imbalance.
Natural bio-identical progesterone cream is an excellent way to restore progesterone balance, because it is painless, applied in the privacy of your own home, and has few side-effects.
Another option is 10 mg of Provera® per day for 10 to 12 days per cycle. Sometimes, resistant bleeding requires two months of continuous Provera®, 20 mg every day. Provera® causes many more side-effects than natural progesterone cream. Your doctor must verify that you do not have an estrogen deficiency first.
Endometriosis and PCOS
Endometriosis occurs when free floating cells from the lining of the uterus exit through the fallopian tubes and migrate around the body. They attach themselves to far distant organs, like the bowels or lungs. When your period occurs, these migrating colonies of endometrial cells bleed, too. There is no place for the blood to readily drain, causing severe pain and scarring.
Natural progesterone is the only hormone that effectively controls endometriosis. For detailed information on natural progesterone’s role in treating endometriosis see www.understandingendometriosis.com
A hormonal imbalance causes polycystic ovary syndrome (PCOS). You probably menstruate heavily, infrequently, irregularly, and painfully. You likely have male-pattern hair growth, such as facial and chest hair.
Natural progesterone is the initial treatment of choice because PCOS is a failure to ovulate and hence there is an absence of progesterone production. By supplementing progesterone the imbalance is corrected and symptoms improve significantly. For detailed information on natural progesterone and PCOS see www.understandingpcos.com
If the underlying cause of your heavy uterine bleeding is endometriosis or PCOS, you may be offered Danazol®, a modified testosterone (male hormone), or another powerful GnRH analogue to suppress your pituitary gland and ovaries. Unfortunately, these modified hormones will put you into sudden menopause, so they are never the drugs of first choice.
Anemia
If the lab finds you have iron deficiency anemia, then your doctor will advise you to take iron supplement pills daily. 300 mg ferrous gluconate or equivalent iron supplement is easier for your stomach to tolerate than ferrous sulphate, but is a little more expensive.
Increase your intake of iron-rich foods, like: Eggs; spinach and other dark green, leafy vegetables; liver; iron-fortified cereal and pasta; beans; nuts; legumes (lentils); dried fruit; and prune juice. Iron requires Vitamin C so that it can be adequately absorbed, so eating these foods also will help: Orange juice; strawberries; broccoli; grapefruits; lemons; kiwi fruit; mangoes; apricots; peppers; tomatoes; cabbage; potatoes; romaine lettuce; turnip greens.
Buy a stool softener (eg Metamucil®) because iron is constipating. If your anemia does not resolve with the iron supplements and dietary changes, you may receive iron injections, blood transfusions, and in extreme cases in-patient care in a hospital.
Taking iron supplements when you do not have iron deficiency anemia causes iron overload and damages your liver. It is important that you verify, with an accredited lab, that you truly have iron deficiency anemia before starting iron supplementation as there are other forms of anemia and conditions that cause fatigue.
Your further treatment options depend on:
- Whether or not you desire contraception
- The timing of your blood loss
- Severity of blood loss
- Your age
- If you are prone to blood clots or endometrial cancer
- The underlying cause of your uterine bleeding (ovulatory hormone imbalance, endometriosis, fibroids, etc.)
More comprehensive information on Dysfunctional Uterine Bleeding (DUB) can be found at www.dysfunctionaluterinebleeding.info
Change Your Contraceptive
Often perimenopausal women exhibiting symptoms are treated with The Pill to “stabilize” the hormones. The Pill overrides the natural hormone production of women and in the case of the perimenopause adds estrogen but fails to address the progesterone deficiency because The Pill doesn’t contain natural progesterone.
Often perimenopausal women who take The Pill find their symptoms worsen rather than improve. This is due to the added estrogen of The Pill not being balanced by natural progesterone and “estrogen dominant” symptoms are exacerbated. The progestin in The Pill does not do what natural progesterone does in terms of balancing the effects of estrogen and therefore The Pill usually aggravates symptoms in an already estrogen dominant woman.
Make sure you let your doctor know that you are aware of the potential for ‘estrogen dominance’ if only The Pill is prescribed and would like progesterone to be considered as an additional treatment.
Copper IUDs increase menstrual blood loss by 50% and commonly cause cramping (dysmenorrhea). Progestin IUDs eg Mirena® reduce bleeding however it can have side effects such as nausea, frequent breakthrough bleeding and may exacerbate mood changes.
Surgical Interventions
If you are older than 40 and do not wish to have more children, or if you are at risk for developing endometrial cancer, then your doctor will offer a combination of medication and surgical intervention.
The first-line treatment is usually progesterone to halt the thickening of the endometrial lining. A dilatation and curettage (D&C) follows, to mechanically reduce the thickness of the endometrium. The endometrium grows back, so it is not a permanent solution.
A D&C can be performed in your family doctor’s office as an out-patient procedure, in a gynecology clinic, or at a hospital. Recovery takes two or three days. You must have the underlying reason for your DUB treated, because repeated D&C is very taxing on your reproductive system.
If D&C is unsuccessful, your doctor may offer an endometrial ablation, which burns off the endometrium. The gynecologist can use a balloon filled with hot water (85ºC, 185ºC), or an electrocautery roller ball, or extreme cold to freeze the tissue.
Emergency Treatment
If you need your period stanched right away because of hemorrhaging, then you will be offered tranexamic acid (Cyklokapron®). Your problem is likely an ovulatory hormonal imbalance creating a lack of progesterone production. Your body produces too much plasminogen activator before your period begins.
Taking one gram of Cyklokapron® every 6 hours for 4 days when the heavy bleeding starts will quickly reduce your blood flow by 40%. Cyklokapron® is also used as an anti-stroke medication, and can cause complications, such as: Dizziness from low blood pressure; visual disturbances, especially color changes and loss of visual acuity; and damage to the retinas in your eyes. If visual disturbances occur, you must stop taking Cyklokapron®.
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