Amanda Newman (00:00):
How heavy is too heavy for a period? When do you worry about iron deficiency? When should you be checked for a bleeding disorder? All that and more on this episode of The Healthiest You.
(00:12):
Many women from adolescence into adulthood cope with heavy menstrual periods. If you feel like you're having to plan your life around when your period comes because of the symptoms you experience, it may be time to take a closer look at your cycle and see if there is an underlying condition.
(00:30):
Welcome back to another episode of The Healthiest You podcast, where we focus on women's health and wellness. I'm your host, Amanda Newman. Whether you're on your way to work or enjoying a cup of coffee, take this time to focus on your health. Here to talk about heavy periods and its connection to iron deficiency and bleeding disorders is pediatric hematologist oncologist Dr. Nathan Hagstrom and pediatric hematology oncology physician assistant Emily Jacobson, with Lehigh Valley Reilly Children's Hospital, part of Jefferson Health.
(01:07):
Dr. Hagstrom and Emily, welcome to the show.
Nathan Hagstrom, MD (01:10):
Thank you.
Emily Jacobson, PA-C (01:11):
Thank you.
Amanda Newman (01:11):
We know that periods are unique to each person and that the menstrual cycle gives us a glimpse of what is going on inside. Hormones, health conditions or stress can all impact your cycle. How do you know, though, if your period is too heavy?
Nathan Hagstrom, MD (01:28):
Well, Amanda, 30 to 50 percent of women at one point during their lifetime will have heavy menstrual bleeding that's relatively chronic. So it can be something that's not recognized because it's so common. In fact, we call it sort of normalizing something that's actually abnormal. And as it turns out, 40 to 50 percent of women who have heavy menstrual bleeding won't seek medical attention.
Emily Jacobson, PA-C (02:00):
Yeah. So as Dr. Hagstrom pointed out, it's become normal to have sort of heavy periods, even among family members as they discuss it. So things that we look for when we talk to our patients are bleeding more than seven days, soaking through either a pad or a tampon every one to two hours consistently. Even if that's only for the first couple of days, it's still important information in order to decide if we think you should be screened for a bleeding disorder. Severe iron deficiency anemia that's recurrent, either previously treated or not. Using sort of double protection. So often patients will say, "Oh, well, I use period underwear and a pad." But that's also not normal. Clots that are passed ... usually greater than quarter-sized is a good kind of indication of abnormal bleeding. And then if the bleeding interferes with their life, and that's really the most important piece.
(02:56):
If their quality of life is affected, whether that's school, work, personal or professional impacts on a day-to-day basis, then it's really abnormal and something that we want to discuss further.
Amanda Newman (03:08):
So aside from heavy periods interfering with daily life, what are some other symptoms women may experience because of heavy periods?
Emily Jacobson, PA-C (03:16):
Yeah, that's a great question. So cramps are common, cramps that are unrelieved by simple pain medication or true lower abdominal pain. Additionally, symptoms that are associated with iron deficiency with or without anemia, such as dizziness, weakness, headaches, pale skin. Difficulty concentrating in school or at work is an important symptom to think about. And then dizziness, especially when you're standing up, is something that some women deal with as well.
Amanda Newman (03:47):
And earlier you both had mentioned iron deficiency. So maybe now would be a good time if we could talk a bit about that.
Nathan Hagstrom, MD (03:55):
Over 70 percent of women who experience heavy menstrual bleeding will have some iron deficiency. And in fact, over half will have a ferritin that's below normal and actually be anemic. It's important to know that iron deficiency can be chronic, but anemia can also be acute when you have heavy menstrual bleeding. So you have this chronic anemia where you're constantly fatigued, maybe have mild headaches. And then during your menstrual period, if you're having a lot of bleeding, you may acutely become anemic and you'll feel weak. You'll have significant dizziness, you're at risk for even falling, and you really do need to seek medical help when you feel those symptoms. But don't ignore the mild ones too, because iron deficiency chronically is not good for your health.
Amanda Newman (04:47):
And could you explain to our audience what ferritin is and what the levels should be?
Nathan Hagstrom, MD (04:54):
Yeah, the ferritin is what we call a surrogate marker. So it's a blood test that indirectly measures something important in your body, and that is your iron stores. You store your iron in your liver and your bone marrow, which we're not going to biopsy to test for iron deficiency. So we use this ferritin, and we use a cutoff of about 30 as whether you're iron deficient or not. Now there's other things that can affect the ferritin, so you have to use clinical judgment when you're deciding if a ferritin is too low or too high. The best example is pregnancy. Your ferritin goes up when you're pregnant. So if your ferritin is less than 50 when you're pregnant, you're probably iron deficient.
Amanda Newman (05:38):
And is there something you'd like to add, Emily?
Emily Jacobson, PA-C (05:40):
I think just making more clinicians, physicians and also people aware that what we consider normal as a ferritin, what the lab may consider normal, it may not be an accurate representation of the appropriate level that a patient needs to feel good and feel like they can do their day-to-day work in life.
Amanda Newman (05:57):
And that's why an iron supplement could be really helpful and life changing for someone, truly.
Emily Jacobson, PA-C (06:03):
Exactly, Amanda. Oral iron supplementation is usually where we start. There are different types of oral iron supplements. Some come with more side effects of abdominal pain, constipation, gas, bloating; some come with less. And so usually working with the patient to determine which supplement is the best is really important, and getting our patients to understand that we may have to try more than one supplement first. Obviously, things like including iron in your diet is very important. So fish, red meat, leafy green vegetables, beans, lentils, all those things that we talk about all the time. But oftentimes for our women with heavy bleeding, it's simply not enough. You can't take in enough iron in your diet to overcome what you're losing on a monthly basis. And then ultimately, if the oral iron is not enough or the anemia is significant at that time, sometimes we recommend an infusion.
Amanda Newman (06:53):
Well, thank you for explaining all of those different options that are available. So what causes heavy periods? Is it a genetic condition?
Nathan Hagstrom, MD (07:01):
There are basically three ways to think about this. One is hormonal, some kind of hormonal imbalance where the endometrium buildup is more than it would normally be. The other is anything that makes you bleed more. A bleeding disorder, whether it's something you're born with or even acquired or even being on blood thinners, will make your bleeding worse. And then the third is really if there's something going on in the uterus that needs medical attention, whether it's a benign tumor or even a cancer or something else that's abnormal that needs to be addressed.
Amanda Newman (07:39):
And could you talk about which bleeding disorders are linked to heavy menstrual cycles?
Emily Jacobson, PA-C (07:45):
Sure. So there are a wide array of them, some more common than others. The most common inherited bleeding disorder is Von Willebrand disease, which is obviously a mouthful to say. But it's a very important protein that exists in our blood and for our clotting system. It helps our platelets, which are cells that help us clot, bind and stop bleeding. And so it helps create a strong clot and slow down the amount of blood loss. There are many different types of Von Willebrand disease. Type 1 being the most common, meaning that you just don't have enough of the protein. Some of the other types are about how the protein works and functions. And then the least common is type 3, which is you don't have any Von Willebrand protein in your body.
(08:27):
The other types of bleeding disorders that we commonly see and treat are hemophilia. So it's a common misconception that only boys can be symptomatic from hemophilia, both A and B, because it is an X-linked disorder. But women who are carriers of hemophilia can have levels in the 20s per se, which would put you at significant risk for bleeding complications, both not only from a menstrual bleeding standpoint but also for surgical, dental and other procedures. So it's important if a mom brings their son in and is newly diagnosed with hemophilia, that we're also talking with mom and other family members, whether that brother have sisters, older or younger, to see if they have any bleeding complications of their own so that they can get tested appropriately. And then there are other different types of inherited or acquired. For example, you can have issues with your platelets. ITP is one of the more common types that we see in an acute setting. Idiopathic thrombocytopenia purpura, which is your body creates antibodies to those platelets.
(09:32):
And so acutely you have low platelets and that can lead to increased bleeding. And then there are other factors that play into our coagulation cascade. One of the more common things that we're talking about these days is basically having a bleeding phenotype or you have a lot of bleeding, but we're not able to sort of put a diagnosis to it. And that can be difficult to help our patients understand, but also to treat.
Amanda Newman (09:55):
And if you're already struggling with a heavy menstrual period and then you could even also have a bleeding disorder on top of that. I mean, I just can't even imagine how difficult that is to be dealing with because you're feeling exhausted and just not like yourself and probably feeling a little hopeless at times.
Emily Jacobson, PA-C (10:13):
Yeah, absolutely.
Nathan Hagstrom, MD (10:15):
It's important to know if you have a bleeding disorder because there are other complications with surgery, childbirth, dental extractions, where if we can recognize that you have something that we can pretreat before you have procedures or have a risk of bleeding – or at least you just know that your heavy menstrual bleeding can be treated a different way than just with the other hormonal and other treatments. So we encourage people that have heavy menstrual bleeding, who also have a history of easy bruising or prolonged bleeding with cuts and abrasions or a family history of a bleeding disorder, that they should be tested. And if you're young, meaning you've had heavy menstrual bleeding from the time you first start having your periods as a young teenager, that puts you at higher risk for having a bleeding disorder, and you should get tested.
Amanda Newman (11:08):
So some women live with these symptoms that we've been talking about today for a long time and maybe have accepted them because their symptoms were either unfortunately dismissed or they may have been told it's just simply part of womanhood. So for the ladies who are quietly dealing with this, what advice would you give them and how can they get diagnosed and start to heal?
Emily Jacobson, PA-C (11:30):
So one of the most common things we say is, "Well, my period's heavy, but so is my sister's and so is my mom's, so that's normal." And that's because it's what we've been told our whole life. This is something we just have to deal with, suck it up, go to school, go to work. But really that's an inappropriate way to handle this. So advocating for yourself is really important and saying, hearing this, hearing some of the symptoms that we talked about, if you or a loved one are experiencing any of this, going to your doctor and saying, "Look, I'm worried about this. It may be normal for me, but I don't think it's normal in the population." And really putting yourself out there. On the hematology side of thing, we receive referrals all the time from our lovely clinicians and physicians who see our young women who recognize that their bleeding patterns are not normal.
(12:19):
So advocating as the patient, but also as the clinician, asking the important questions, asking somebody to characterize their bleeding, not just, "Oh, is your bleeding heavy?" But what does that actually mean and what is considered abnormal in order for these women to feel like they can speak up and be heard?
Amanda Newman (12:33):
I love that you mentioned the word advocate there. That's so important because I very much am hearing exactly what you're saying. Like, when you're growing up, it's just normalized, like, "Oh, my mom had a heavy period. I have a heavy period." And you don't think anything of it. And you go to school and you're feeling exhausted and everything, and here there could be something going on much deeper that needs to be addressed.
Emily Jacobson, PA-C (12:57):
Exactly.
Amanda Newman (12:58):
And is there anything else you'd like to add, Dr. Hagstrom?
Nathan Hagstrom, MD (13:01):
I think it's important for people to know that seeking medical help may make a difference for you, both coming up with a diagnosis that needs to be treated or could be treated to prevent complications in the future. But also you may have an iron deficiency that just by supplementing you'll have a better quality of life. You'll feel better and you'll be able to function better and just live a better life.
Amanda Newman (13:28):
Well, Dr. Hagstrom and Emily, thank you both so much for joining us today and sharing so much helpful information with our listeners.
Nathan Hagstrom, MD (13:36):
Our pleasure. Thank you for having us.
Emily Jacobson, PA-C (13:38):
Thank you so much.
Amanda Newman (13:40):
Since there's more to talk about, we'll be continuing our conversation in Part Two of our podcast series where we'll talk about ways to manage heavy periods with OB-GYN Dr. Cori Shollenberger. Thanks for joining us today and stay tuned for Part Two coming soon.
