What You Should Know About Heavy Menstrual Periods with Dr. Cara King

Podcast Transcript

Cassandra Holloway:  Hi, thanks for joining us for this episode of the Health Essentials podcast, brought to you by Cleveland Clinic. I'm your host, Cassandra Holloway. We're broadcasting from Cleveland Clinic's main campus in Cleveland, Ohio, and we're here today with Dr. Cara King. Thanks for being here.

Cara King:  Absolutely, thanks for inviting me.

Cassandra Holloway:  Dr. King is the Director of Benign Gynecologic Surgery at Cleveland Clinic's Women's Health Institute, and today we're going to be talking about heavy periods, also known as menorrhagia, and abnormal uterine bleeding. Before we begin, we just want to remind our listeners that this is for informational purposes only and should not replace your own doctor's advice.

Cassandra Holloway:  So, even with modern medicine, that time of the month can still be a big pain for most women, especially those who are prone to heavy bleeding during their periods, and periods in general, there's a big spectrum of what's normal, what's not normal. Let's start off with just explaining, if I was a patient meeting with you, how would you define having a heavy period versus a typical or normal period?

Cara King:  Yeah, and you're exactly right, in that periods can be very variable amongst different patients. So, in general, a period typically comes about once a month, but we define normal as between anywhere between 24 and 38 days, so there is some variance within that. The flow we say is usually between five and eight days, and so if your flow is longer than eight to ten days, for sure, that would be considered abnormal.

Cara King:  Now, the flow can be more difficult to quantify as normal or abnormal, because it's such a subjective description. The way we define it, though, usually is if you are soaking a tampon or a pad within an hour, so I usually say soaking a pad front to front, side to side, within an hour for more than two hours straight, or if you're passing large clots, and we define that usually as bigger than a golf ball. So, if those things are happening, then that would be considered heavy bleeding and should be addressed.

Cassandra Holloway:  Bigger than a golf ball, that's... I thought I read about a quarter size, but it's up to a golf ball size clots?

Cara King:  They can get quite large, yeah.

Cassandra Holloway:  Wow.

Cara King:  Like grapefruit size sometimes, so... I know. Everyone's a little bit different.

Cassandra Holloway:  What are those clots?

Cara King:  So, a clot is really just old blood. When you have your period, blood can pool within the uterus, within the cervix, or within the upper vagina, and so when blood pools there, it can form a clot. Some women will notice it when they go from seated to standing and pass those clots.

Cassandra Holloway:  So you said anything longer after eight to ten days should kind of ring that alarm in your head that this is not standard.

Cara King:  Yeah.

Cassandra Holloway:  Okay.

Cara King:  Yeah, exactly right. Yeah, we define it between five and eight days, but I oftentimes say, if it's impacting your quality of life, have it evaluated.

Cassandra Holloway:  Absolutely, yeah.

Cara King:  So, again, if it's impacting you in a negative way, even if it's less than eight days, I say come in and have it evaluated.

Cassandra Holloway:  Sure. How common are heavy periods? Do you see that a lot, that condition a lot?

Cara King:  Very, very common. So, about one-third of all visits to the gynecologist are because of abnormal uterine bleeding. When I see my patients, inevitably my patients usually apologize for having bleeding when they come and see me, and I tell them, "Every single person in my waiting room is having abnormal bleeding probably right now." So it's very common, and from a physician's standpoint, it's nothing to be embarrassed about. It's what we do as gynecologists on most days.

Cassandra Holloway:  I like how you said it, if the heavy period is affecting your quality of life, if you're stopping activities because of it, that should be another alarm in your head to get this checked out, to get this handled.

Cara King:  Yes, absolutely. And if you see your physician and you're having really painful periods, or really heavy periods, and they say, "Oh, don't worry, it's fine, it's normal, it's just you having your period, that's what it's like to be a woman," I urge you to get a second opinion. That's okay. Be an advocate for yourself in regard to evaluating these things, because painful, really heavy periods aren't normal, and they should be looked into.

Cassandra Holloway:  Absolutely. I'm curious, if a woman is experiencing heavy bleeding, does she have a regular cycle, for the most part, or is it kind of irregular? Is there any kind of standard to that?

Cara King:  Yeah, so there is some variance, and so we say anywhere between 24 and 38 days, within that range is normal, and each month, it can be off a little bit, maybe between five and seven days variant from... So, five to eight days variable from your last period. So, some irregularity can be normal, but you shouldn't be skipping months, and you shouldn't be spotting regularly in between periods. So, if you're skipping more than two, three months at a time, and you're not on anything to make that happen, meaning if you're not on anything for hormonal suppression, and you're skipping more than two to three months, that's not normal, and that should be evaluated, because your lining can be getting really thick, and if you have uncontrolled thickening of your lining, it increases your risk of hyperplasia or malignancy.

Cara King:  Same on the other end: If you're having a lot of spotting in between periods, that can also be a sign of an abnormality. Sometimes it can be a structural abnormality inside your uterus, or variable other things, and that should be looked into. And another thing that should never be ignored is if you're having any bleeding after menopause. That's never normal, so any bleeding, heavy, light, spotting, brown, red, no matter what, if it's after menopause, that should be evaluated.

Cassandra Holloway:  Gotcha. So, I want to talk a little bit about the causes of heavy periods. What are some of those causes for that?

Cara King:  There's many, many causes for abnormal uterine bleeding, and we kind of break it down into growth issues or structural abnormalities, and so these things can include fibroids or polyps or different growths inside the uterus. It also can be secondary to something called adenomyosis, which is also a different type of growth issue, which is when the lining of the uterus can actually grow inside the muscle wall of the uterus. Certain medications can increase your risk of having abnormal bleeding. Birth control, so, some forms of birth control, when you first start them, can give you abnormal uterine bleeding. Especially if you're on a birth control pill and you're missing pills here and there, that can also instigate an episode of bleeding.

Cara King:  Cancer, which is obviously the most worrisome cause, can also be secondary... Or, I should say, bleeding can be a sign of cancer. And the main cancer that can be associated with this bleeding is endometrial cancer or uterine cancer, but cervical cancer can also be related to this.

Cara King:  The final cause that I oftentimes think about is actually when people have a history of cesarean sections, and nowadays, a lot of people have previous C-sections. You can actually get a little, we call it a niche, or a little defect in that endometrial lining by your C-section scar that actually can pool with blood and cause some irregular bleeding in between periods too.

Cassandra Holloway:  That's really interesting, I didn't know that.

Cara King:  Yeah. I'll oftentimes ask about your surgical history when you come in.

Cassandra Holloway:  And you're more prone to heavy periods because of the C-section scar, in some cases.

Cara King:  Yeah, in some cases, especially irregular spotting, which sometimes can be heavy.

Cassandra Holloway:  Gotcha. I did want to ask about cancer; I know you said it's a scary topic. Is there a percentage of people who experience heavy bleeding that do go on to get diagnosed with these cancers? Is that something you can answer?

Cara King:  Yeah, so in regard to endometrial cancer, there's different risk factors that can increase your risk of having a uterine malignancy, and so, depending on the risk factors that you have, will increase your risk of having that bleeding be associated with something like a cancer. So, in regard to endometrial cancer, things that would increase your risk of having cancer associated with your bleeding would be morbid obesity, so if you have a higher BMI, that is the number one risk factor for having endometrial cancer, as well as high blood pressure and diabetes, as well as age. So, if you're over the age of 45 and have these other risk factors, especially, we'll want to evaluate your lining. If you're under the age of 45 and are having abnormal uterine bleeding and have these risk factors, we may want to evaluate your lining as well.

Cassandra Holloway:  Interesting. You mentioned the growth issues earlier, about different growths or polyps causing the heavy bleeding. You'd mentioned fibroids. Is that the number one cause of heavy menstrual bleeding? Why is that?

Cara King:  Yeah. Fibroids are extremely common. We're not exactly certain why some women get them, but we do know that about 80% of women will be diagnosed with fibroids by the time they hit the age of 50, which is like everybody, right?

Cassandra Holloway:  Wow, yeah, right?

Cara King:  I mean, eight out of ten women, that is a tremendous amount of women. The good news is that they're very, very rarely associated with cancer. So, only less than 1% of fibroids are associated with a type of malignancy, and also, only about 20% of women actually need surgical intervention for their fibroids. So, they're extremely common. Oftentimes, we can control the heavy bleeding with certain medications, and I'd say overall, fairly rarely do they need surgical intervention.

Cassandra Holloway:  So, maybe it's a scary term, but it's, like what you're saying, it's very common, it's very treatable.

Cara King:  Absolutely, yeah. And fibroids can grow anywhere within the uterus, and if the fibroids are on the outside of the uterus, or if they're smaller in the wall of the uterus, they probably aren't causing symptoms, they don't need to be managed surgically.

Cassandra Holloway:  You don't need to worry about it then? Yeah.

Cara King:  Yeah, no, no. Yeah, you don't need to worry about it. If they're in the lining themselves, that can lead to the heavy bleeding and oftentimes need to be addressed.

Cassandra Holloway:  Gotcha. So, what about heavy periods and fertility? Does that affect ovulation? How does that work?

Cara King:  Yes, great question. So, in regard to fertility and heavy bleeding, if we look at it from an ovulation perspective, an ovulatory bleeding, meaning if you're not ovulating regularly, that can lead to heavy bleeding. So, if you're having regular periods, what happens is that the lining can continue to build up, and then when you do have your period, it's extra heavy. So again, if we're putting you on something to stop your periods, like a birth control pill or an IUD, and you're not having periods because of that, absolutely no problem. That's great. We're thinning your lining out and just making it so you don't have a period. But if you're not having regular cycles, and you're not ovulating regularly, then we care that you're missing periods, because the lining can keep getting thicker.

Cassandra Holloway:  I want to talk about diagnosis and treatment now. At what point would your advice be to someone who's maybe experiencing these heavy periods? Should they wait a couple cycles for it to kind of even out, or should they make an appointment and come in right away?

Cara King:  So, as a general rule, I say if you have only one single heavy period, and it's not associated with anything scary like anemia symptoms, it's okay to wait that one cycle out. Now, if you're having a really heavy bleed, again, soaking a pad front to front, side to side, changing that more than once an hour, or having anemia symptoms like dizziness, vision changes, headache, racing heartbeat, or feeling like you're going to pass out, that should be evaluated right away. If those things aren't happening, I think it's okay to have one heavy period and then suss out how things go from there. But if you have repetitive heavy periods, I'd say come in and see us.

Cara King:  And it can be really helpful to keep a log, meaning the day that your period starts, the day it ends, what your flow was like. If you're on some kind of hormonal contraception, mentally know if you're missing any pills. Those things can be really helpful when you come to your doctor.

Cassandra Holloway:  You mentioned anemia, so I want to talk a little bit about that. Is that the most common side effect of heavy bleeding, because you're losing so much blood?

Cara King:  Yeah, you're exactly right. With heavy periods, you're exactly right, in that just sometimes, you're bleeding so much that your hemoglobin actually drops. And some people have such chronic, meaning they've had such heavy bleeding for so long, they're anemic and they don't even realize it. So some people are used to living at this really low hemoglobin, which can be dangerous, and people can feel fatigued and not even realize that that's the cause.

Cassandra Holloway:  Wow.

Cara King:  Yeah.

Cassandra Holloway:  So, walk us through, if a woman were to come into your clinic and talk about heavy period bleeding, what tests would you run to determine this?

Cara King:  So, after we have a really good conversation about the exact specifics of the bleeding, then we usually turn to a physical exam, because there can be a lot of different sources of the bleeding. So, once we do a good physical exam and I feel what the uterus feels like, meaning are there any extra fibroids that I can feel, adenomyosis symptoms, things like that that I can feel on physical exam, then we move over to the diagnostic testing. In regard to lab work, the first thing I always want to make sure is rule out pregnancy, because if you're having bleeding and you're pregnant, that could be a surgical emergency or an issue, and so we always test for pregnancy, and then we also typically test for anemia, just like we stated, so we'll get a complete blood count to see what the hemoglobin level looks like.

Cara King:  If I'm concerned about anovulatory bleeding or some kind of endocrine disorder, we may also add on some thyroid testing, because sometimes if an endocrine abnormality is present, that can lead to some bleeding. Or if I'm worried about somebody with low platelets or some other bleeding disorder, we may test for that as well in the lab work. And then, in regard to imaging, usually we start out with an ultrasound, and that ultrasound may just be a regular vaginal ultrasound to look at the uterus. Sometimes we do something called a saline infusion sonogram, where we put water inside the uterus and then do an ultrasound then, which can give us a better idea of what's going on in the cavity.

Cassandra Holloway:  Figure out first what you need to treat, basically, and then treat that underlying cause.

Cara King:  Exactly right, yeah.

Cassandra Holloway:  So then, what does treatment look like? Are there surgical interventions, is it medicine? Can you talk a little bit about treatment?

Cara King:  Yeah. So, once we figure out the exact source, then we can really narrow in a great treatment plan. We try to save surgery for the very last intervention, so we typically try to start with medications first. Medications can include iron supplements if we're worried about anemia. We also have a really amazing blood management team here who can help with IV iron transfusions and try to eliminate the need for an actual blood transfusion, so we'll oftentimes include them in our plan. Medications may also include hormonal measures, so things that can stop periods, like the birth control pill, the patch, the NuvaRing, an IUD, things like that. And there's also a good non-hormonal medication, something called tranexamic acid, which can help decrease the flow and the clots, and you only take that during the actual days of bleeding, so five days a month, which can be really nice for many patients.

Cassandra Holloway:  Yeah, absolutely. What about... You mentioned birth control to kind of control some of that bleeding. What if someone is having heavy periods, but they're trying to get pregnant? Do you have any advice for treatment for that?

Cara King:  Yeah. Yeah, you nailed it. So, if somebody's trying to get pregnant, birth control is not a good option for them. That's not very helpful. So, if that's the case, then we really want to make sure that their uterine lining looks good, so if there's any kind of polyp there or fibroid there that may need to be addressed surgically. And so, you're exactly right that if someone wants to get pregnant, then hormonal options would not be a good route, and so at that time, we'll do a really good investigation of what their myometrium looks like, what their endometrium looks like, and try to target any kind of anatomical pathology that may be there.

Cassandra Holloway:  Makes sense. And then, if left untreated, do heavy periods cause any long-term issues that people should be concerned about?

Cara King:  The main thing we care about is this anemia and this chronic anemia, so once we rule that out, and all the ramifications that anemia can lead to, meaning low blood volume can lead to cardiac issues and other issues along that line, the other main thing would be if you're skipping long months and then having those heavy periods, then we care about the risk of hyperplasia or malignancy. So, those are the two main things that I think about with heavy bleeding.

Cassandra Holloway:  Gotcha. So, last thing I want to touch on here is just your general advice to a listener who maybe has been experiencing some heavy bleeding and searching online for these answers. What's your advice or recommendation that you would give her? Should she come in right away? Would you console her that this is treatable, it is common? What would you tell her?

Cara King:  Yeah. I'd say this heavy abnormal bleeding can be very, very common. I would recommend that she try to keep some kind of log of her bleeding profile, meaning days that she's bleeding, the heaviness, and any other medications that she's taking, and that may help guide her when she comes into the office. I'd also, again, state that if you're having any bleeding after menopause, that is absolutely not normal, and that requires immediate attention.

Cara King:  And then the last thing I'd say is that if surgical intervention is the best step for the patient, and the surgeon or your physician recommends surgery, always investigate minimally invasive surgical options. So, even very large pathology, meaning very, very large fibroids, can typically be done with a laparoscopic approach, and so if your physician is recommending an open or abdominal procedure, I would urge that patient to seek out a second opinion with a minimally invasive GYN surgeon. I'd also say that if you do have very large fibroids and the physician is recommending a full hysterectomy, also seek a second opinion, because very commonly, we can do uterine preservation procedures to save the uterus, take out just the pathology, and again, most commonly through a laparoscopic approach.

Cassandra Holloway:  That's great advice, thank you.

Cara King:  Yeah.

Cassandra Holloway:  Thanks for being here.

Cara King:  Absolutely, thanks again for having me.

Cassandra Holloway:  Of course. So, thanks for joining us to our listeners. If you'd like to schedule an appointment with Cleveland Clinic's Ob/Gyn and Women's Health Institute, please visit clevelandclinic.org/womenshealth, or call 216-444-6601. If you want to listen to more Health Essentials podcasts featuring Cleveland Clinic experts, subscribe wherever you get your podcasts, or visit clevelandclinic.org/hepodcast. And don't forget, follow us on Facebook, Twitter, and Instagram @clevelandclinic, all one word, to stay up to date on the latest health tips, news, and informations. Thanks for listening.