Here come the flash periods

Among many unexpected symptoms that crop up during perimenopause, your menstrual cycle can get completely out of whack. (Photo: NYTime)
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. اضافة اعلان

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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