The Sensitive Nature of the Subject May Have Hampered Awareness, Treatment, and Relief
Tiredness and lack of vitality are integral to menopause, alongside hot flashes, disrupted sleep, and emotional fluctuations.
Nevertheless, the irregular or heavy menstrual bleeding that frequently happens during menopause and the perimenopausal phase rarely features in discussions surrounding the management of symptoms that detrimentally impact women’s quality of life.
The Menopause Rating Scale, the most commonly used measure to evaluate menopause symptoms in research, omits inquiries regarding menstrual bleeding.
Recent research spearheaded by the University of Michigan is believed to be the first to investigate the relationship between prolonged and heavy menstrual bleeding and fatigue as women near menopause. The study, published in Menopause, tracked 2,329 midlife women who maintained menstrual diaries and completed yearly surveys from 1996 to 2005.
Lead author Sioban Harlow, professor emerita of epidemiology and obstetrics and gynecology, shares insights from the research.
What distinguishes your study from previous research on menopausal transition?
While prior menopause studies have recorded the occurrence of fatigue symptoms, few have documented alterations in menstrual duration or flow, and none have examined the potential influence of these changes in bleeding on common menopause symptoms, such as sleep disturbances and fatigue. This study stands out as we have methodically recorded monthly menstrual calendars and collected data on fatigue symptoms over a decade as women navigated menopause.
Your research seeks to uncover whether abnormal bleeding is the biological cause of menopausal fatigue, tiredness, or low energy, correct?
Indeed. As women approach menopause, when menstruation ceases permanently, the duration and volume of menstrual bleeding often intensify. Up to one-third of women may experience excessive menstrual bleeding—lasting longer than eight days, or exhibiting very heavy flow requiring frequent changes of pads or tampons, sometimes resulting in bleeding through clothing. Blood loss also leads to iron depletion, and heavy menstrual bleeding can result in iron deficiency, a common symptom of which is fatigue.
Even though many midlife women experiencing menopause often report feelings of tiredness or fatigue, these causes go largely unaddressed in both popular and scientific literature. Fatigue during menopause may stem from interrupted sleep due to hot flashes or from breakthrough bleeding necessitating nighttime sanitary product changes. However, fatigue can also surge in association with an enhanced risk of iron deficiency and anemia resulting from severe menstrual bleeding.
Why do you think changes in bleeding—which are such a fundamental aspect, if not the most apparent aspect of menstruation—aren’t discussed or researched more frequently?
Historically, menopause studies have concentrated on the postmenopause phase, which occurs after the final menstrual period when women have ceased bleeding. Variations in menstrual bleeding happen during the menopause transition or perimenopause, a period when many menopause symptoms, like hot flashes and sleep disruptions, first manifest. This stage of reproductive life averages five years but may extend up to ten years.
Moreover, menstruation remains a taboo subject, rarely discussed publicly, leaving women with minimal understanding of what constitutes normal bleeding or the changes they are likely to encounter as they approach menopause, including occurrences of excessive bleeding. Scientific exploration of menstrual disorders is not prioritized, despite the potentially serious health ramifications of abnormal uterine bleeding.
What key message do you want women to derive from these findings?
Severe and/or extended menstrual bleeding is common during the menopause transition and can be linked to fatigue, either by disturbing sleep or through the loss of iron. Both abnormal uterine bleeding and fatigue significantly affect quality of life and have dire health implications, but both conditions are manageable and do not need to be merely endured. It may sometimes be a challenge to find a healthcare provider who is knowledgeable and willing to address your concerns, making it essential to locate a supportive and informed practitioner.
And what about healthcare providers?
Primary care physicians receive limited education regarding menstruation and menopause. It is crucial for them to acknowledge that abnormal uterine bleeding often escalates during the menopause transition and may lead to serious health outcomes like fatigue. As both conditions are manageable, providers should inform women about the comprehensive array of treatment possibilities. When assessing fatigue, it’s essential for providers to consider a patient’s menstrual history.
Why do you and your co-authors advocate for future research on abnormal uterine bleeding?
The menopause experience spans both the transition and postmenopausal phases. We require better data on the prevalence of abnormal bleeding during the transition and its effects on women’s quality of life and health. Understanding how abnormal uterine bleeding may correlate with other menopause symptoms—such as sleep issues, cognitive difficulties, and social challenges—is imperative. Women need this information.
Co-authors of the study include Michelle Hood, Alain Mukwege, and John Randolph from the University of Michigan; Gail Greendale from UCLA; and Ellen Gold from the University of California, Davis.
