The menopausal transition: Counsel on changes in bleeding patterns
Executive Summary
Results of a national study indicate it is not uncommon for women to have prolonged bleeding of 10 or more days, spotting for six or more days, and/or heavy bleeding for three or more days during the transition to menopause.
• Of the more than 1,300 women ages 42-52 in the study, 91% recorded one to three occurrences in a three-year period of bleeding that lasted 10 or more days, nearly 88% reported six or more days of spotting, and close to 78% recorded three or more days of heavy flow.
• Knowledge of what to expect provides an important frame of reference and can help clinicians better understand and evaluate the bleeding changes women experience during the menopausal transition.
Prolonged and heavy bleeding during transition is common, study shows
Results of a new national study indicate it is not uncommon for women to have prolonged bleeding of 10 or more days, spotting for six or more days, and/or heavy bleeding for three or more days during the transition to menopause.1 Of the more than 1,300 women ages 42-52 in the study, 91% recorded one to three occurrences in a three-year period of bleeding that lasted 10 or more days, nearly 88% reported six or more days of spotting, and close to 78% recorded three or more days of heavy flow.
Data for the Study of Women’s Health Across the Nation (SWAN) involved participants recording their experiences over a period of time during the years 1996 to 2006. The women were identified as African-American, Japanese, Chinese, and white, and they were from southeast Michigan, Los Angeles, and northern California.
For most women, menstrual cycles in the reproductive years before the menopausal transition starts are very predictable, observes Sioban Harlow, PhD, professor of epidemiology at the University of Michigan in Ann Arbor. With the onset of the menopausal transition, their menstrual cycles change, often dramatically, she says. "Knowledge of what to expect provides an important frame of reference and can help clinicians better understand and evaluate the bleeding changes women experience during the menopausal transition," states Harlow, who served as lead author of the current paper.
The paper provides clinicians with quantitative data that describe the likelihood women will experience long and heavy bleeding during the menopausal transition, notes John Randolph, Jr., MD, professor of obstetrics and gynecology at the University of Michigan. Most women will experience one or more periods that are longer than what they are accustomed to, but these long periods are often self-limiting, notes Randolph, a paper coauthor. Periods of 10 days are not uncommon, unlike what most women experience during their reproductive years, says Randolph.
"Such long and/or heavy bleeding would prompt clinical investigation by the accepted standards of care in women prior to the menopausal transition," states Randolph. "These data can be used to explain why clinicians may suggest watchful waiting during the transition."
Discuss bleeding patterns
The report from SWAN investigators regarding bleeding patterns across the menopause transition is a "great addition" to the literature, says Margery Gass, MD, NCMP, executive director of the North American Menopause Society in Mayfield Heights, OH. It will be comforting to women to know they are not alone in dealing with irregularity, she notes.
However, as the paper’s authors point out, pathology reports were not available, so neither women nor clinicians should fail to discuss bleeding patterns in perimenopause, states Gass. Clinicians must use good judgment in deciding when to try hormonal control of the bleeding and when to evaluate the endometrium, she notes.
Clinicians also should take into account the relative progesterone deficiency during this phase of,2 and remember that obesity is not only a risk factor for heavy bleeding, but also a risk factor for endometrial cancer, states Gass.
The current paper’s findings might help clinicians reduce the numbers of endometrial biopsies performed on perimenopausal women who have single episodes of heavy or prolonged bleeding, says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles.
According to Nelson, the current paper’s findings follow in the same line as research published in 2010, which showed that the highest blood losses are seen in late menopausal transition with ovulatory cycles and high estradiol levels.3 Nelson also points to a 2012 publication, where in a survey of 2,051 naturally menstruating women, two-thirds reported heavy menstrual bleeding in the previous six months. Follow-up showed that 30% of the remaining third developed problems in the next two years, which indicates heavy menstrual bleeding to be a very common problem indeed, Nelson notes.4
What’s your approach?
The current study demonstrates the importance of asking women about their bleeding pattern during the menopausal transition, says Susan Wysocki, WHNP-BC, FAANP, president & chief executive officer of iWomansHealth in Washington, DC, which focuses on information on women’s health issues for clinicians and consumers.
Questions about bleeding can become so routine that important information might be lost if additional information isn’t elicited, Wysocki observes. Clinicians need to ask, "What has changed about your menstrual bleeding pattern since your last visit? What do these changes mean to you?" Each woman is going to have a different concept of what the changes mean to her, whether the changes are bothersome or worrisome, and how they might be having an impact on her life, says Wysocki.
It also is important to consider that some bleeding might not be related to the transition into menopause and should be investigated, because it could be related to some pathology or sexually transmitted infection, Wysocki states. Consider that several things can transition during this time of life, including relationship changes, she says.
Hormonal contraceptive methods can be important options in managing bleeding, notes Wysocki. No contraceptive method is contraindicated based on age alone; however, estrogen-containing methods should be reserved for women without cardiovascular or thrombotic risk factors.5 Progestin-only methods as a group can be used by virtually every perimenopausal woman. Only women with a recent history (five years or less) of breast cancer carry a category 4 (a condition that represents an unacceptable health risk if contraceptive method is used) for progestin-only pills.6
The levonorgestrel intrauterine system has particular benefits during perimenopause and is safe for use in nearly all women.5 Use of the device is approved for treatment of heavy menstrual bleeding, a common concern during the perimenopause. In a randomized study of women who presented with excessive menstrual bleeding, the levonorgestrel intrauterine system was more effective than other medical treatments, such as tranexamic acid, nonsteroidal anti-inflammatory drugs (NSAIDS), combined oral contraceptives, progestin-only pill, and the contraceptive injection, in reducing the effect of heavy menstrual bleeding on quality of life.7 (Contraceptive Technology Update reported on the research. See "See nonsurgical options for abnormal bleeding," June 2013, p. 67.)
- Paramsothy P, Harlow S, Greendale G, et al. Bleeding patterns during the menopausal transition in the multi-ethnic Study of Women’s Health Across the Nation (SWAN): A prospective cohort study. BJOG 2014; doi: 10.1111/1471-0528.12768.
- Hale GE, Hughes CL, Burger HG, et al. Atypical estradiol secretion and ovulation patterns caused by luteal out-of-phase (LOOP) events underlying irregular ovulatory menstrual cycles in the menopausal transition. Menopause 2009;16(1):50-59.
- Hale GE, Manconi F, Luscombe G, et al. Quantitative measurements of menstrual blood loss in ovulatory and anovulatory cycles in middle- and late-reproductive age and the menopausal transition. Obstet Gynecol 2010; 115(2 Pt 1):249-256.
- Shapley M, Blagojevic M, Jordan KP, et al. The spontaneous resolution of heavy menstrual bleeding in the perimenopausal years. BJOG 2012;119(5):545-553.
- Baldwin MK, Jensen JT. Contraception during the perimenopause. Maturitas 2013;76(3):235-242.
- Nelson AL. Perimenopause, menopause and postmenopause. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
- Gupta J, Kai J, Middleton L, et al. Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med 2013;368(2):128-137.
