heavy menstrual bleeding

Heavy menstrual bleeding (HMB) is a common experience for women entering perimenopause. Many women who previously had regular, manageable cycles may notice a sudden shift, with heavier bleeding and irregular periods becoming more frequent. This shift often coincides with the hormonal changes associated with perimenopause, as ovarian function declines and the balance between estrogen and progesterone begins to fluctuate.

Heavy menstrual bleeding can occur throughout a woman’s reproductive life for various reasons, including conditions like endometriosis or uterine fibroids. During perimenopause, it is primarily linked to an imbalance between estrogen and progesterone as ovarian function changes.

 

The Role of Progesterone in the Menstrual Cycle

Progesterone is a crucial hormone produced during the luteal phase (the second half) of the menstrual cycle. Its primary function is to stabilise the endometrial lining, preparing it for potential implantation of a fertilized egg. If pregnancy doesn’t occur, falling progesterone levels signal the body to shed the lining, resulting in menstruation.

One of the first hormonal shifts during perimenopause is a decline in progesterone production. Without sufficient progesterone, the endometrial lining may become thicker than usual, leading to heavier bleeding when the period begins. Additionally, irregular ovulation is common during perimenopause, further contributing to hormonal imbalances and erratic bleeding patterns.

For a deep dive into the menstrual cycle – watch this video.

 

Menstrual Fluid

A typical menstrual period consists of roughly 50% blood and 50% other secretions, such as endometrial tissue (the lining of the uterus), mucus and other fluids

The upper limit for normal menstrual blood loss is around 80 ml, which equates to approximately 160 ml of total fluid when including the other components. However, measuring this fluid loss can be difficult, so healthcare providers rely on practical indicators to diagnose heavy menstrual bleeding.

The following signs suggest that menstrual bleeding is heavier than normal:

• Needing to change tampons or pads more frequently than every two hours
• Passing clots larger than 2 cm
• Soaking through menstrual products onto clothing
• Needing multiple menstrual products at the same time (e.g., tampon + pad)

Heavy menstrual bleeding is concerning because it can contribute to iron deficiency, which is surprising common in women.

Symptoms of iron deficiency overlap with common perimenopausal symptoms and may include fatigue, brain fog, muscle weakness, shortness of breath on exertion, feeling cold, anxious, irritable, heart palpitations, hair loss, dry skin, restlessness, and trouble sleeping.

Because many of these symptoms are also associated with menopause, it’s crucial not to overlook iron deficiency as a potential cause. Iron deficiency can often be easily corrected through supplementation and by addressing the underlying cause of heavy menstrual bleeding. There are other causes of iron deficiency, unrelated to HMB, which your doctor will consider.

 

Treatment Options for Heavy Menstrual Bleeding

Fortunately, HMB during perimenopause can be managed similarly to how it’s treated during other phases of reproductive life- with a combination of medications, hormonal therapies, and in some cases, surgical interventions.

These treatments all have different benefits. Some can be used for other perimenopausal symptoms and or contraception.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are an effective treatment for HMB because they help constrict blood vessels in the shedding endometrial lining, reducing blood flow. However, higher doses than typically used for pain relief are required for this purpose. These often require a prescription.

• Naproxen: 500 mg twice a day
• Ibuprofen: 800 mg three times a day
• Mefenamic acid: 500 mg three times a day.

NSAIDs should be taken at the first sign of bleeding and continued until menstrual flow becomes light.

Tranexamic Acid

Tranexamic acid is another medication used to reduce menstrual bleeding by slowing down the breakdown of blood clots. Originally developed for surgical purposes, it’s now used to manage heavy periods as well. It requires a prescription.

These 2 approaches are simple, effective, and only requires medication during menstruation itself. Some women are unable to use them for medical reasons.

Hormonal Treatments

Hormonal treatments are often the most effective way to control heavy menstrual bleeding during perimenopause. Several options are available, each with unique benefits:

• Combined Oral Contraceptive Pills (COCs): These pills control the hormonal fluctuations that lead to heavy bleeding. Continuous or extended-use COCs can prevent periods for up to three months or longer. COC will stabilse hormone levels and treat perimenopausal symptoms.
• Progestin-Only Pills: Progestins* helps regulate the endometrial lining, reducing bleeding and often lightening periods. They also provide contraception and given they control the brain – ovary communication, can improve early perimenopausal symptoms.
• Progesterone Therapy: This can be used in the luteal phase to limit bleeding, or continuously for two to three months at higher doses than those used in standard menopausal hormone therapy (MHT) protocols. Luteal progesterone may help cyclic symptoms of perimenopause. Progestins  also help reduce HMB when used only in the luteal phase, but do not provide contraception.
• Levonorgestrel Intrauterine Device (IUD). The Mirena IUD is an excellent solution for women with HMB, especially during perimenopause. Many women stop having periods altogether when using it. This method also protects the endometrial lining if using oestrogen MHT and provides contraception.

Surgical Treatments

In some cases, medication and hormonal treatments may not be enough to control HMB, especially if it’s associated with other conditions like endometriosis or fibroids. Surgical options include:

• Endometrial Ablation: A procedure that destroys the lining of the uterus to reduce or stop bleeding.
• Hysterectomy: The removal of the uterus is sometimes necessary but should be considered a last resort after other treatments have been tried.

There is growing concern about high rates of hysterectomy, particularly in Australia, so exploring all other options—such as medication and ablation—before opting for surgery is essential.

Heavy menstrual bleeding during perimenopause can be distressing, but understanding the hormonal changes behind it can help you manage the symptoms effectively.