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This, and the article called “Managing Menorrhagia—Effective Medical Treatments” for your doctor or health care
provider, are to help you avoid surgeries for heavy flow (hysterectomy and endometrial ablation) if you can.
The good news is that, in a large study of pre- and perimenopausal women, heavy flow was not caused by
endometrial cancer. This means that a diagnostic test for cancer called a D & C (a surgical procedure in which
the endometrium is scraped off) is not necessary (3). Heavy flow was most common and occurred in 20% of
women ages 40-44 (3). In women ages 40 to 50, those with heavy flow commonly also have fibroids. However
higher estrogen with lower progesterone levels causes both heavy bleeding and the growth of fibroids. Fibroids
are benign tumors of fibrous and muscular tissue that grow in the muscle of the uterine wall; less than 10% come
close to the endometrium and are called “submucus” fibroids. Only these rare fibroids could possibly influence
flow. So fibroids are rarely the real cause for heavy flow and are not a reason to treat very heavy flow any
differently.
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Early in
4/20/2019 perimenopause when cycles are regular,
Very Heavy Menstrual approximately 25%
Flow | The Centre for of women
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period. Perimenopausal estrogen levels are higher and progesterone levels are lower (4;5). (See Perimenopause,
the Ovary’s Frustrating Grand Finale.) Progesterone levels are lower because ovulation is less consistent and short
luteal phases (the portion of the normal menstrual cycle from ovulation until the day before the next flow) with
fewer than 10 days of progesterone are common in perimenopause (6).
Some rare reasons for heavy flow are an inherited problem with bleeding (like hemophilia), infection or heavy
bleeding from an early miscarriage.
Progesterone therapy makes sense because very heavy flow is associated with too much estrogen for the amount
of progesterone. Progesterone’s job is to make the endometrium thin and mature—it antagonizes estrogen’s
action that makes it thick and fragile. However, low doses given for two weeks or less a cycle are not effective
(9). One study shows that very high doses of a strong progestin for 22 days a cycle decreased bleeding by 87%(10).
I recommend starting treatment with oral micronized progesterone (Prometrium®) 300 mg at bedtime or
medroxyprogesterone (10 mg) taken days 12-27 of the cycle. (See Cyclic Progesterone Therapy handout.). Always
take progesterone for 16 days whenever you start it for heavy flow (even if flow starts before then). If needed,
progestin can be started right away, at any time of the cycle and will slow or stop the bleeding.
Heavy bleeding is so common in perimenopause that when a woman over 40 is traveling or will be in a remote
place, she should ask her doctor for a 16-day supply of 300 mg of oral micronized progesterone (or 10mg
medroxyprogesterone tablets) to take with her.
You are likely in very early perimenopause if flow is extremely heavy, you already have anemia or it has been
going on for a long time progesterone needs to be taken daily for three months. Take oral micronized
progesterone 300 mg at bedtime daily and continued, every day, for three months. Flow will become irregular but
decrease in amount over time. After that you can take cyclic progesterone for a few more months. Also
remember to always take ibuprofen on every heavy flow day.
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As flow
4/20/2019 gets lighter the progesterone therapy
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cycle. In perimenopause, especially in women with a history of acne and unwanted facial hair (PCOS or
anovulatory androgen excess) it is often necessary to treat with daily progesterone therapy for three months to
also decrease the risks for endometrial cancer. Following that it is wise to use a cyclic treatment for days 12
through 27 of the cycle for six more months.
Wrapping up section
In summary, very heavy menstrual bleeding means soaking 12 or more regular sanitary products in one period.
About 25% of women in very early perimenopause or early menopause transition, some teens and a few women of
other ages will experience this. No matter at what age heavy flow occurs, using a menstrual cup will help prevent
embarrassing leaks and allow less frequent visits to the washroom. At present more than 50% of North American
women with very heavy flow end up with a hysterectomy that can almost always be avoided. Very heavy flow can
be helped by ibuprofen (1-2 tablets with every meal on every heavy flow day), extra salty things to drink,
increasing dietary or supplemental iron and with cyclic progesterone or medroxyprogesterone. If flow is heavy in
perimenopause progesterone will need to be taken daily for three months. Finally, a strong progestin-releasing
IUD, Mirena® has been shown to be effective for both heavy flow and for contraception.
References
1. Hallberg L. Menstrual blood loss. Acta Obstet Gynecol Scand 1966; 45:320.
2. Cole SK Sources of variation in menstrual blood loss. J Obstet Gynaecol Br Commonw 1971; 78:933.
3. Allen DG. Abnormal uterine bleeding and cancer Aust N Z J Obstet Gynaecol 1990; 30:81.
4. Santoro N. Reproductive hormonal dynamics in the perimenopause. J Clin Endocrinol Metab 1996; 81:1495.
5. Prior JC. Perimenopause: Endocr Rev 1998;19:397.
6. Prior JC.Ovulatory changes with perimenopause. Novartis Found Sym 2002; 242:172.
7. Fraser IS Treatment of menorrhagia with mefenamic acid. Obstetrics and Gynecology 1983; 61:109.
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8.
4/20/2019 Casper RF MinestrinTM on vaginal bleeding
Very Heavy Menstrual patterns in symptomatic
Flow | The Centre perimenopausal
for Menstrual Cycle women. Menopause
and Ovulation Research
1997; 4:139.
9. Preston JT Tranexamic acid and norethisterone in the treatment of ovulatory menorrhagia. Br J Obstet
Gynaecol 1995; 102:401.
10. Irvine GA. Randomised trial of the levonorgestrel intrauterine system and norethisterone for menorrhagia.
Br J Obstet Gynaecol 1998; 105:592.
11. Bonnar J Treatment of menorrhagia BMJ 1996; 313:579.
12. Marjoribanks J Surgery versus medical therapy for heavy menstrual bleeding. The Cochrane Database of
Systemic Reviews 2003; 3:1-65.
13. Casper RF, Dodin S, Reid RL, Study Investigators. The effect of 20 µg ethinyl estradiol/1 mg norethindrone
acetate (Minestrin™, a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality
of life in symptomatic perimenopausal women. Menopause 1997; 4:139-147.
Author: Dr. Jerilynn C. Prior, Scientific Director, Centre for Menstrual Cycle and Ovulation Research
Type: Articles
Topic: Heavy flow, Progesterone therapy
Life Phase: Adolescence, Premenopause, Perimenopause
Updated Date: October 4, 2017
© 2019 The Centre for Menstrual Cycle and Ovulation Research | Website by Raised Eyebrow Web Studio
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