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Nicole Pauzano, a 49-year-old school psychologist, faces an overwhelming challenge each month due to perimenopausal bleeding. “I’m bleeding through ultra-tampons in less than 2 hours to the point where they’re completely saturated, and I’m bleeding beyond backup pads into my clothing,” Pauzano shared, describing the severity of her condition.
Perimenopause, the transitional phase occurring 6-7 years before and up to a year after menstruation ends, is notorious for causing mood swings, sleep disturbances, hot flashes, night sweats, and, for some women, excessively heavy menstrual bleeding—often referred to as ‘the menopausal flood.’ Despite the debilitating nature of this condition, many women do not seek medical help, leaving the true prevalence of this issue unclear.
Susie Parker, a 49-year-old PR consultant, also experienced heavy, painful periods starting around age 40. “They were very debilitating in the sense that I could not really leave the house without feeling like I might have some sort of accident out in public,” she recalled. Parker’s condition improved significantly after she underwent an ablation, a procedure that removes the lining of the uterus.
From a medical perspective, excessively heavy menstrual bleeding refers to a menstrual flow that deviates significantly from the norm in terms of volume, duration, regularity, or frequency. Dr. Lisa Taylor-Swanson, an integrative health specialist and assistant professor at the University of Utah, recounted treating a patient who had bled menstrual fluid into her shoes after eight months of heavy bleeding. Unfortunately, her primary care doctor dismissed her symptoms as typical for perimenopause and did not provide treatment.
This experience is not uncommon. Dr. Sophia Yen, co-founder and chief medical officer of Pandia Health, emphasizes that women should not accept excessive bleeding as a normal part of menopause. “If you see giant clots greater than the size of a quarter, if you’re going through more than a pad (or tampon) an hour, if it’s unusual for you specifically, then it’s definitely something to be concerned about. If you have any bad bleeding, please see a doctor to have it worked up,” Yen advised.
Dr. Marisa Messore, a certified menopause practitioner based in Miami Beach, FL, echoed this sentiment. “Excessive menopausal bleeding can be due to many things – it could be related to hormonal changes or fluctuations, but there could also be other things that need to be evaluated, like structural problems with the uterus, polyps, etc.,” she said. Other potential causes include blood clotting issues, thyroid problems, or even cancer, making a thorough medical evaluation crucial.
Anemia is a common consequence of excessive blood loss, affecting about 58% of women with perimenopausal bleeding. Seeking a specialist in menopause and gynecology for a diagnostic workup is ideal, but these practitioners can be difficult to access. According to the Menopause Society, there are 3,000 certified menopause practitioners globally, with less than half residing in the U.S. Additionally, a 2023 survey revealed that only 31% of OB/GYN residency programs include menopause in their curriculum.
Before seeing a practitioner, Dr. Yen recommends tracking the number of days with excessive bleeding and the number of pads or tampons used each day. This information can be recorded in phone notes or on the Menopause Society’s menstrual bleeding calendars.
Determining how much bleeding is too much can be challenging. “There’s quite a bit of data showing that women who are 50 bleed 6 millimeters more than women aged 20 to 45; some bleed as much as 133 ml (the accepted definition is 80 ml or more),” said Taylor-Swanson.
Treatment Options
The goal of treatment for the menopausal flood ranges from regulating menstrual cycles and reducing blood loss to improving overall quality of life. Treatment choices depend on factors such as fertility desires and the presence of other medical conditions.
Hormonal options are often the first line of treatment. “We’re in a time of more personalized medicine, and we want to tailor treatments for the patient and to their specific symptoms,” Messore said. Progesterone-releasing IUDs, progesterone-only pills, and estrogen/progesterone pills are commonly used to manage heavy bleeding and other conditions like endometriosis and polycystic ovary syndrome.
Non-hormonal treatments include medications that reduce inflammation or slow bleeding, such as tranexamic acid, and procedures like endometrial ablation. Acupuncture is another option supported by Dr. Taylor-Swanson. “Acupuncture helps the body stay in the middle of the road in terms of cycle regulation – not too heavy, too light, too frequent, not too far apart,” she explained.
Regardless of the treatment chosen, finding a practitioner who can provide a comprehensive plan for the menopausal transition is vital. “It can take a few years; it’s not a one-stop thing; it’s a process,” Messore said.
