Heavy Periods During Perimenopause Linked to Fatigue, Anemia

• A recent study found that abnormal menstrual bleeding during perimenopause is associated with fatigue.
• If left untreated, heavy menstrual bleeding can lead to iron deficiency anemia, a well-known cause of fatigue.
• Females should report midlife menstrual changes like prolonged or heavy bleeding to their doctor to discuss treatment to help ease discomfort.

Irregular menstrual cycles during midlife, or changes in the amount and duration of menstrual flow, is often a telltale sign of perimenopause.

This phase before menopause, known as the menopause transition, typically affects females in their mid to late 40s and early 50s, though the age of onset may vary significantly.

Unlike menopause, which is confirmed when a person has gone 12 months without a period, perimenopause is often characterized by abnormal menstrual bleeding.

Heavy menstrual bleeding during perimenopause can significantly impact quality of life.

A recent study found that heavy or prolonged menstrual bleeding may lead to fatigue, which helps explain why females are two to four times more likely to experience syndromic fatigue during midlife, which can be debilitating, researchers say.

The results, published online on March 12 in Menopause, the journal of The Menopause Society, note that 1 in 3 perimenopausal females experienced abnormal uterine bleeding.

Despite this prevalence, few studies have examined the issue nor have they explained the link between abnormal uterine bleeding during the menopause transition phase and fatigue or decreased quality of life.

Heavy bleeding may cause iron deficiency anemia (low red blood cell count), which, while treatable, is a well-known cause of fatigue.

“This study highlights the need for greater clinical awareness of abnormal uterine bleeding, particularly given the increased frequency during the menopause transition and its association with low energy or fatigue symptoms,” said Stephanie Faubion, MD, director of the Mayo Clinic Center for Women’s Health and medical director for The Menopause Society, in a news release.

“Educating women about the possibility of prolonged or heavy menstrual bleeding during the menopause transition and the potential health consequences is also needed,” she noted.

Perimenopause onset begins with declining ovarian function and reproductive hormone shifts, resulting in a drop in estrogen production and leading to various menopause-like symptoms, such as:

• hot flashes
• sleep difficulties
• chronic pain
• depression and mood changes

In this new study, researchers examined menstrual tracking calendars for 2,300 midlife females to determine whether they experienced heavy or prolonged menstrual bleeding over the course of six months.

They assessed feelings associated with fatigue (i.e., feeling tired, worn out, low energy).

After adjusting for other possible causes of fatigue, they found a strong link between heavy and prolonged menses and fatigue.

The researchers suggest that more awareness of abnormal uterine bleeding during perimenopause is needed.

“Changes in menstrual bleeding are common in perimenopause, Faubion told Healthline. “Periods can become lighter or heavier. This relates to fluctuations in ovarian function and subsequently in brain neurochemicals, such that the brain is trying to get the ovary to respond.”

“When that happens, the ovary is being ‘flogged’ by the brain, which can result in higher levels of estrogen than a woman usually has in her reproductive years. This can lead to thickening of the uterine lining and heavier menstrual blood flow,” Faubion added.

Signs of midlife menstrual changes, such as heavy or prolonged bleeding, may include:

• irregular menstrual cycles
• menses lasting longer than 7 days
• unusually heavy flow needing frequent changing of menstrual products
• passing large blood clots
• bleeding that interferes with everyday activities

Heavy menstrual bleeding is not always related to hormone changes during perimenopause, however.

Abnormal uterine bleeding may also be related to other causes not associated with menopause transition, such as uterine cancer, Faubion noted.

“It’s always important that abnormal uterine bleeding be evaluated because bleeding could be a sign of something more serious,” Faubion said.

The new study’s authors say clinicians should assess energy levels when patients report bleeding changes to determine the right course of treatment, especially if there is a risk of anemia.

“If a woman is experiencing heavy menstrual bleeding in perimenopause, it should be evaluated and treated,” Faubion said.

If you’re concerned about midlife menstrual changes, ask your doctor for guidance to help you navigate this transition.

• hormonal treatments​ (i.e., combined oral contraceptives)
• non-hormonal medications (i.e., NSAIDs)
• progestin-containing IUDs
• ​endometrial ablation (a medical procedure that removes the uterine lining to help reduce menstrual flow)
• hysterectomy (in severe cases only)

Your doctor might also advise certain self-care strategies to help ease discomfort, such as:

• tracking menstrual changes
• using menstrual products for heavier flow
• taking iron supplements
• stress management
• maintaining a balanced diet
• exercising regularly

“There are many options for reducing bleeding during this time,” Faubion said. “In other words, they shouldn’t just ‘put up with it.’”