Prolonged and Heavy Perimenopausal Bleeding
Frederick R. Jelovsek MD
"I have been having a menstrual cycle for the past month and had one last August too. Any information??? Still ongoing and today with clots passing and great rushes of discharge."
"I am 46 and my menses were normal until about 10 months ago. " sara
Episodes of prolonged menses lasting for a month or more can infrequently occur at any age, however they are more common after age 40 and especially in the 2-4 years before menopause. Sometimes the cause is an abnormal physiologic hormonal response to a skipping of ovulation, while at other times there may be an anatomical cause of bleeding such as a fibroid, a polyp, an overgrowth of the uterine lining (hyperplasia) or even a cancer of the endometrium or uterus.
Over the age of 40, the steps to go through are to diagnose the cause of the bleeding and then treat according to the suspected cause. In general, it is a mistake to treat with any hormonal therapy to slow or stop the bleeding until cancer of the endometrium has been eliminated as a possible cause.
What are the steps to go through in order to diagnose the cause of the bleeding?
- Rule out cancer - usually done by an office endometrial biopsy
- Rule out an intracavitary fibroid or polyp - vaginal ultrasound or vaginal sonohysterogram
- Check for abnormal thyroid hormone (TSH) levels
- If there is a long history of prolonged or heavy menstrual bleeding, an inherited coagulopathy should be considered.
In our office the usual protocol is to do a pelvic exam and
- if the uterus is felt to be normal size, go ahead and perform an endometrial biopsy.
- If the biopsy is negative for hyperplasia or cancer, start hormonal treatment.
- if the uterus cannot be felt or if it is enlarged or irregular, we order a vaginal ultrasound or saline sonohysterogram.
- If there is any abnormality of the symmetry of the endometrial cavity, we will usually recommend a hysteroscopy and D&C so that we can be sure that any lesion inside the uterus is removed as best as possible and sent to pathology.
- If the cavity is symmetrical, go ahead with the endometrial biopsy and if the biopsy is negative for hyperplasia or cancer, start hormonal treatment
Sonohysterography is over 90% accurate for lesions of the endometrial cavity while regular vaginal ultrasound is only about 50-75% accurate (!) but it is less costly and less painful than a sonohysterogram.
Thyroid function also should be checked because a low thyroid hormone level is more likely to be associated with skipping menses and heavy menses (menorrhagia) (1). In women, there is an overall incidence of hypothyroidism of about 6%. It rises with age to be about 8% over age 65 and about 4% in the perimenopausal age range (1).
Sometimes an inherited deficiency of coagulation factors such as that found in von Willebrand's disease may not be diagnosed until later in life when presenting as heavy uterine bleeding (1). This study found a 17% incidence of inherited coagulopathies when thoroughly working up women with menorrhagia. A bleeding time lab test may be used to screen for von Willebrand's but also an activated partial thromboplastin time (aPTT), and a von-Willebrand-factor activity should be measured in all patients to pick these up.
What if polyps or submucosal fibroids are found as the cause of the bleeding?
If the polyps are removed at D&C, then the bleeding problems should go back to the usual menstrual pattern within a month or two. Occasionally endometrial polyps may recur but it takes several years before they do and produce abnormal bleeding again. Polyps probably account for about 10% of perimenopausal bleeding problems (1).
Fibroids are a somewhat different problem. They can cause bleeding in two different ways. Submucosal fibroids actually protrude into the endometrial cavity and bleed just like a polyp would - usually due to direct irritation of a vascular protuberance that rubs on the surfaces of the endometrial cavity with everyday normal activity.
Some fibroids, however, are mainly in the muscle of the uterus (intramural). They grow big enough to bulge under the endometrial lining where the blood vessels feed the endometrial lining. They interfere with the ability of the blood vessels to contract to stop bleeding after the normal menstrual sloughing. They usually cannot be removed by hysteroscopy and D&C because one will comprise a major part of the uterine wall. If the fibroids are removed by myomectomy using a major abdominal incision, the procedure is extensive as an entire hysterectomy. thus it is uncommon to treat uterine bleeding problems due to intramural fibroids with a myomectomy unless a future pregnancy is desired. Recently, arterial embolization of fibroids has been reported to successfully treat heavy menstrual bleeding (1).
What if an endometrial hyperplasia or cancer is found on biopsy or D&C?
If any type of endometrial hyperplasia is detected by endometrial biopsy, a full D&C is indicated because endometrial cancer often coexists with hyperplasia and sometimes hyperplasia can be confused with cancerous changes so a larger sample is needed (1). If the biopsy shows atypical endometrial hyperplasia, some authors consider that as serious as cancer (30% may progress to cancer over time) and therefore recommend hysterectomy as a treatment just as if there were an early cancer (1).
When endometrial cancer is found, the usual treatment is exploratory surgery with hysterectomy and lymph node sampling. Then depending upon the stage of invasion and the pathological characteristics of the tumor (grade), further surgery, radiation or chemotherapy is suggested if any further treatment is needed.
What hormonal treatments are successful if there is not an anatomic cause of the perimenopausal bleeding?
Since most of the bleeding problems stem from irregular or absent ovulation, hormonal therapy is often geared toward controlling the menstrual cycle by blocking ovulation. This can be done by birth control pills in non smokers or injectable depot medroxyprogesterone acetate (DepoProvera ®) which blocks almost all bleeding. Sometimes danazol (Danocrine ®) can also be used instead of progestins and some investigators feel this may be superior to a progestin if there is a hyperplastic endometrium (1).
If ovulation is still taking place, the bleeding also may be able to be controlled by cyclic oral progestins such as medroxyprogesterone acetate (Provera ®) given for 10-14 days starting about 14-16 days after the start of the previous menses.
Are there any other non hormonal treatments that can help the bleeding?
Vitamin K is a factor needed for clotting and a deficiency state of Vitamin K can be a cause of excessive and prolonged menstrual bleeding (1). It is not common to be deficient in vitamin K, but if there is any gastrointestinal disease or poor nutrition, then this should be considered. Sometimes supplements may help lessen bleeding.
Vitamin C (ascorbic acid) is a building block of collagen and of capillaries. Deficiencies lead to bleeding problems of various types. Some studies have suggested that a higher percent of the population has either a deficiency (6%) or low levels (30%) than what we usually think of as a problem (1). Its use has not been studied much for menorrhagia but some of our readers feel it has been helpful to them as noted in the health tips section of our newsletter. Smokers especially may be subject to decreased levels (1). A supplement of 250mg per day of vitamin C is about twice the daily recommended dose (1).
For women who are having heavy or prolonged bleeding and are not on anticoagulants, supplements of vitamin C, 250-500 mg and vitamin K, 100-250 mcgm should be safe and may be worth trying over several months.