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Abnormal menstrual bleeding, a likely culprit in menopausal fatigue, rarely discussed as cause
Taboo nature of topic may have stifled understanding, treatment, relief
Fatigue and lack of energy are as much a part of menopause as hot flashes, interrupted sleep and mood swings.
However, the abnormal or heavy menstrual bleeding that commonly occurs during menopause and perimenopause seldom enters the conversation on treating the symptoms that negatively affect women’s quality of life.
Even the most frequently used scale to assess menopause symptoms in research studies, the Menopause Rating Scale, doesn’t include questions about menstrual bleeding.
New research led by the University of Michigan is believed to be the first to evaluate the link between heavy and prolonged menstrual bleeding and fatigue and lack of pep as women approach menopause. The study, published in Menopause, follows 2,329 midlife women who kept menstrual diaries and completed annual surveys from 1996 to 2005.
Lead author Sioban Harlow, professor emerita of epidemiology and of obstetrics and gynecology, shares her thoughts on the study.
What makes the study distinctive, different from prior studies on menopausal transition?
Although menopause studies have documented the prevalence of symptoms of fatigue, few studies documented the changes in menstrual duration or flow and none have explored the potential role that these bleeding changes may play in provoking common symptoms of menopause, including sleep disruptions and fatigue. This study is unique in that we have prospectively recorded monthly menstrual calendars and gathered information on symptoms of fatigue over a period of 10 years as women transitioned through the menopause.
Your study is trying to get at whether abnormal bleeding is the biological origin of menopausal fatigue, tiredness or lack of pep, correct?
Yes. As women approach menopause, when they permanently stop menstruating, menstrual bleeding tends to increase in duration and amount of blood flow. For up to one-third of women, menstrual bleeding can be excessive—lasting longer than eight days or having very heavy flow that requires very frequent changes of pad or tampons and may be accompanied by bleeding through one’s clothing. When we lose blood, we are also losing iron, and heavy menstrual bleeding can lead to iron deficiency. A common symptom of iron deficiency is fatigue.
Although midlife women going through menopause often report feeling tired or fatigued, the causes of this fatigue are seldom discussed in the lay or scientific literature. Fatigue in menopause may be related to disrupted sleep due to hot flashes or to breakthrough bleeding and the need to change sanitary pads/tampons during the night. However, fatigue may also increase in association with an increased risk of iron deficiency/anemia stemming from excessive menstrual bleeding.
What are your thoughts on why changes in bleeding—such an integral part, if not the most obvious, part of menstruation—aren’t studied more, talked about more?
Historically, menopause research has focused on the postmenopause, that is the time following the final menstrual period, when women have stopped bleeding. Changes in menstrual bleeding occur during the menopause transition or perimenopause, when many of the symptoms of menopause, such as hot flashes and sleep disruptions, also first appear. This reproductive life stage lasts five years on average, but can last as long as 10 years.
However, it is also true that menstruation remains stigmatized and is seldom discussed in public spaces, leaving women with little common knowledge about what amount of bleeding is normal or about the menstrual changes they are likely to experience as they approach the menopause, including episodes of excessive bleeding. Scientific investigation of menstrual dysfunction is not prioritized, despite the health consequences of abnormal uterine bleeding.
What do you want women to most take away from the findings?
Very heavy and/or prolonged menstrual bleeding occurs frequently during the menopause transition, and can be related to fatigue either by disrupting your sleep or because when we bleed we lose iron. Both abnormal uterine bleeding and fatigue can impact quality of life and have serious health consequences, yet both conditions are treatable and need not simply be suffered. Sometimes it may be difficult to find a health care provider who is knowledgeable and will listen to your concerns, so it is important to find a knowledgeable and understanding provider.
And what about health care providers?
Primary care providers receive limited training about menstruation and menopause. It is important for primary care providers to recognize that abnormal uterine bleeding increases during the menopause transition and may have important health consequences including fatigue. As both conditions are treatable, providers should provide women with information about the full range of treatment options. When evaluating fatigue, providers should include a menstrual history.
Why do you and your co-authors call on future research abnormal uterine bleeding?
The experience of menopause encompasses both the menopause transition and postmenopause. Better data is needed about the frequency of abnormal bleeding in the menopause transition and its impact on women’s quality of life and health. We need to understand the extent to which abnormal uterine bleeding may be related to other menopause symptoms including sleep disturbances, cognitive fog and social disability. Women need this information.
Co-authors include Michelle Hood, Alain Mukwege and John Randolph of U-M; Gail Greendale of UCLA; and Ellen Gold of the University of California, Davis.
