In 2016, Alisha Coleman, a 52-year-old 911 call-center
worker in Georgia, was fired from her job because she started experiencing a
hallmark symptom of perimenopause: unpredictable and heavy periods, also known
as flash periods.
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Once, her period was so heavy, she bled through her clothes
and onto an office chair. Another time, she leaked onto the carpet. Those
instances, as her employer put it, amounted to a failure to “practice high
standards of personal hygiene” while on duty, and were reason for termination.
While Coleman’s case may be extreme, it points to a major
lack of information around perimenopause — the transition phase to menopause —
and the day-to-day challenge of dealing with a menstrual cycle so thrown out of
whack that it interferes with a woman’s quality of life and productivity, said
Dr. Siobhan Harlow, a professor of epidemiology at the University of Michigan
School of Public Health. (Coleman sued the company for sex discrimination and
the two sides eventually settled. Dozens of other lawsuits include allegations
of menstrual or menopausal sex discrimination.)
A study that analyzed the menstrual cycles of 1,320 women in
the menopause transition found that 78 percent experienced periods that lasted
more than 10 days (the average period can last up to seven days).
More than one-third of women in the study, of which Harlow
was a co-author, experienced periods that were so heavy they had to change
their sanitary products every one to two hours for more than three days —
compared with a more normal flow, which requires changing products every four
to eight hours.
“At this life stage, it’s no longer true that women know
when they’re going to bleed or how much they’re going to bleed,” Harlow said.
Still, she added, this symptom is rarely studied or discussed among women
themselves.
Why do periods go haywire?
It all comes down to “the sputtering ovaries,” said Dr.
Malcolm Munro, an obstetrics and gynecology professor at the David Geffen
School of Medicine at UCLA.
In a regular cycle, the ovaries make estrogen to nurture an
egg for release and thicken the uterine lining for its arrival, Munro said.
Once the egg is released, the ovary also emits progesterone,
which stops the lining from growing and changes its structure to make it a
soft-landing place for a fertilized egg. If there is no fertilized egg, the
ovary stops producing progesterone, which triggers menstrual bleeding.
Progesterone is also responsible for stopping menstrual bleeding after a few
days, he said.
Think of the uterine lining “like grass in your garden,”
Munro said. Estrogen acts like water that helps the grass grow and progesterone
is the equivalent of “cutting the grass every four weeks” and keeping it tidy,
rather than letting it grow unchecked.
It is a spectrum
As a woman enters the menopause transition, the ovaries make
less estrogen and have fewer eggs to release, which means there might be cycles
where ovulation doesn’t occur at all, throwing off the delicate balance of
hormones, Munro said. “It’s not an on and off circumstance,” he said, “it’s a
spectrum.” In some women, it can lead to long gaps between each period because
there is no progesterone.
The absence of progesterone can also lead to a buildup of
the lining, which can “randomly fall off” and trigger unusually heavy periods,
he said. Or, for other women, there might be so little estrogen that the
uterine lining hasn’t grown much, leading only to some light spotting.
Smoking and body mass index were associated with higher risk
Harlow found in her study that smoking and a higher body
mass index were associated with heavier bleeding in perimenopause, although
it’s unclear why. Black women were more likely than white, Chinese or Japanese
women to have heavier bleeding.
There are some risks linked to hormonal imbalances in
perimenopausal women — key among them is endometrial cancer, said Dr. Ekta
Kapoor, assistant director of the Mayo Clinic Center for Women’s Health. During
the perimenopause phase and even after a woman has had her final period, the
absence of progesterone means the uterine lining can continue to grow and
become abnormally thick — a condition called endometrial hyperplasia, which can
turn cancerous, she said. One of the telltale signs of endometrial hyperplasia,
Kapoor said, is heavy periods.
In cases where women have immensely heavy periods, Munro
said, they might also experience iron deficiency and anemia, which in turn can
be connected to other common menopause symptoms, including fatigue and brain
fog.
What can you do to manage flash periods?
The first thing is to determine whether your irregular
periods are being caused by menopause-related hormonal shifts or if there might
be another culprit, such as fibroids or endometrial hyperplasia. While there
are no official guidelines on when to see a doctor, if several cycles have been
irregular and heavy, that’s a sign to seek help. “That needs to be worked out
with imaging or, in some cases, an endometrial biopsy,” Kapoor said.
If the problem is purely hormonal, women can consider oral
birth control options or a hormonal intrauterine device, Kapoor said, both of
which can help smooth out hormonal imbalances. Another option is taking
progestin pills. It might also be “reasonable and practical” to keep period
products handy at all times, she said. Harlow noted that many women carry
towels with them or a change of clothes.
If the hormonal options don’t seem to work, women might
consider speaking to their doctors about an endometrial ablation — surgically
destroying the endometrial lining — to stop heavy bleeding, or a hysterectomy.
It should be noted, that those options are “a little
drastic” and should be seen as last resorts, Kapoor said, given that the
menopause transition, which can last anywhere from four to eight years, is a
temporary phase of life and “an end is usually in sight.”
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