Perimenopausal Bleeding: When Do I Worry?

Women in their forties often experience changes in the amount and/or frequency of their menstrual flow. This can affect lifestyle by causing fatigue and limiting activity. Some women must remain confined to home or at least within immediate proximity to a bathroom for days at a time. A woman’s mother or aunt may have had a hysterectomy for similar bleeding–raising concerns that surgery might also be in her future. We are often asked, “When do I get concerned?”

In general, menstrual cycles tend to shorten (i.e., menses get more frequent) as menopause approaches. This is a slow process occurring over the course of several years. They usually stay regular during this transition–every 23 or 24 days versus every 28-30 days previously. As the ovaries age and become less efficient, ovulation occurs less frequently. This is reflected in the menstrual cycle as a more pronounced irregularity; for example, cycles that will vary from 14-40 days or more in length. These patterns are generally hormonal and therefore benign.

Bleeding patterns that may signify a problem are those that tend to be prolonged and progressive. Prolonged meaning that the pattern persists over several months. Progressive meaning that every cycle seems to get worse, more and more heavy or perhaps longer and longer. A day or two of heavy bleeding is usually tolerable. Four or five is not. Changes such as this could signify a problem and should be discussed with your healthcare provider. The same is true for bleeding that lasts 10-12 days or more, even if light.

Your mother probably had a D&C performed to evaluate her bleeding. This approach is now considered outmoded. Nowadays a simple pelvic ultrasound usually suffices to make a diagnosis. It allows accurate identification of most pelvic pathology and allows a discussion of treatment options. And the key point here is that there are options. If you have menstrual symptoms that are worrisome, discuss them with your provider and get involved with the decisions about your care.

What is Black Cohosh and what is its relation to menopause?

Black Cohosh is scientifically known as Actaea Recemosa, a North American herb that is a member of the buttercup family. It was originally used in North American Indian medicine for malaise, sore throat, rheumatism, malaria, kidney disorders, and gynecological disorders, as well as reduce hot flashes and other menopausal symptoms. No human studies have adequately evaluated the effect of Black Cohosh on the endometrium (the inside layer of the uterus) or vagina.

Black Cohosh contains biological components similar in structure to the human hormone estrogen. A number of studies have suggested that these plant hormones attach to the estrogen receptors in the body. This activity decreases the amount of luteinizing hormone which is associated with temperature fluctuations. Other studies have not been able to confirm this mechanism of action which leaves scientists questioning why Black Cohosh seems so effective.

Currently, it is sold as a dietary supplement; dietary supplements are regulated as foods and not drugs. Because dietary supplements are not always tested for consistency, the composition may vary.

Short term use of Black Cohosh, specifically for periods no longer than six months, was endorsed by the American College of Obstetrics and Gynecologists (ACOG) in 2001. This limited used is recommended because the herb reduces symptoms of menopause without any danger. ACOG suggests using the Black Cohosh at a dosage of one to two 20 mg pills twice daily. Black Cohosh can cause stomach upset and headaches.

Disclaimer: In accordance with FDA regulations, this information is not to be used for purposes of diagnosis or treatment. This information is not intended to be taken as a replacement for medical advice. It is strongly recommended that you talk to your provider-physician, nurse-midwife, nurse practitioner, or physician assistant – about any herbal therapy you are using or would like to use in order that he or she may best provide care for you. It is important that many prescription medications are not duplicated with herbal treatments.

Harbour Women’s Health has a commitment to providing you the option of combining traditional medicine with alternative approaches, many of which they provide. If you have any questions regarding Herbal Therapy in Women’s Healthcare please free to ask.

What websites would you suggest for research on women’s health?

In this day and age, the internet is an amazing resource that we can all benefit from if used judiciously. However, there is a tendency when one has a medical concern to simply “google” a particular subject and end up with a variety of websites to investigate. There are countless websites to explore but the integrity and medical accuracy of each site varies. The following list includes links to resource we consider helpful and accurate.

At Harbour Women’s Health we advocate for women to learn as much as they can about their health and their bodies but do not want them to become overwhelmed or anxious with the information they discover. For this reason, we have previewed certain websites in an effort to strategically focus your searches on reliable websites.

Heart Health
A clearinghouse of information on women’s health. The site is run by United States Division of Health and Human Services and the Division of the National Women’s Health Information Center. Lots of good information on heart health as well as bacterial vaginosis, carpal tunnel syndrome, and breastfeeding.
A fine site sponsored by the popular weight loss business. Recipes and instruction on healthy weight loss.

This website is sponsored by the Foundation for Better Health Care. The menopause patient education module is concise and has a great introduction to the topic.
Sponsored by Planned Parenthood, this site has a fair overall view of topics of concern to the perimenopausal and menopausal woman.
Sponsored by the National Sleep Foundation, they have a review of sleep issues, not only during menopause, but also at other challenging times in women’s lives. Constructive suggestions are offered for improving each night’s rest.

Sponsored by the National Osteoporosis Foundation, up-to-date information on prevention and continuing education seminars for professionals.

Sexually Transmitted Infections
Great resource for increasing your knowledge about any sexually transmitted infection, including herpes, hepatitis, and HPV. Run by American Social Health Association.

Sexual Health and Public HealthSexual Health and Public Health
The Alan Guttmacher institute is a well-known organization which has advanced studies regarding contraception and sexual health for men and women. They have an ambitious national and international agenda for women’s health. Great research site.
The Women’s Sexual Health Foundation supports a multidisciplinary approach to the treatment of sexual health issues and serves as an educational resource for public and healthcare professionals.

Resolve is a national support organization for women and men struggling with infertility.


All of the above websites are excellent resources for women with any questions/concerns about breastfeeding.

Adolescent Health

Two excellent websites for adolescent women learning about their sexuality and sexually transmitted infections.

Happy Browsing.

OSTEOPOROSIS: What is Osteoporosis?

Your bone is constantly active, balancing reabsorption of old bone and formation of new bone. Bone formation is greater than reabsorption up to age 30. After that, bone is broken down faster than it is reformed. Most of the time this does not cause any problems. After menopause, however, the decreasing amount of estrogen further slows bone formation. The result is bones that are thinner and weaker and more prone to fracture. It is most prominent in the spine, hip, and wrist.

What causes osteoporosis? A small percentage of patients have other diseases which increase their risk. However, many women have risk factors which might increase their individual risks. The greatest risk factors are: family history of osteoporosis, smoking, menopause, lack of exercise, low body weight, diet low in calcium (lifelong) and the use of certain medications.

Can I prevent it? Preventive measures can decrease the risk of osteoporosis. The two most effective measures are calcium and exercise. It should be mentioned that maximum bone density is achieved before age 30 and begins to decrease after that age. Exercise does not mean you have to join a gym. Any weight-bearing exercise such as walking will have a positive effect if it is done regularly.

Having a diet with adequate amounts of calcium and Vitamin D will slow bone loss. (Calcium is not very well absorbed unless Vitamin D is present.) A well-balanced diet is best, but the majority of women will probably not get enough calcium from diet alone. This is most true of women who do not include dairy products in their diets. An amount of calcium to strive for is approximately 1500mg. A cup of broccoli contains about 100mg of calcium whereas a cup of skim milk contains about 300mg. There are many supplements to choose from. It’s best to choose one with Vitamin D included, but there is no convincing evidence that any one type of calcium supplement is better than any others.

How is osteoporosis diagnosed? All women over 65 years of age and younger women with additional risk factors should have bone density testing. This is a painless and very easy test to have and you should discuss this with your practitioner.

Are medications needed? Medications can stop the bone loss and, in some instances, gradually increase bone density. However, the choice of medications should be based on your individual situation and bone density test. Medications have been shown to decrease the occurrence of fracture even when bone density has stayed the same. Medication does not eliminate the need for exercise and calcium.

What is perimenopause and what are some suggestions in terms of managing it?

Menopause is defined as the last menstrual cycle in a woman’s life, and marks the end of her reproductive years. Perimenopause is the term used to describe the time of transition between a woman’s reproductive years and menopause. This period of transition may be quite brief or may last as long as ten years. For many women, this transition begins in the forties and lasts through and sometimes beyond menopause. (The average age of menopause for American women is fifty-one.) A woman can theoretically conceive at any point up until the active time of menopause. Therefore, it is still necessary to use contraception throughout the perimenopause.

During this time, declining ovarian function is associated with changes in the production of estrogen, progesterone, and androgens (the hormones which regulate women’s menstrual cycles). These changes can lead to a variety of symptoms in women, including memory changes; menstrual irregularities (either more or less frequent, and with either a very heavy or light flow); hot flashes or night sweats; libido changes; insomnia; or mood fluctuations including symptoms of irritability, anxiety, or depression. Eventually, women might also experience signs of urinary or vaginal atrophy (meaning a loss of elasticity or thinning of the tissue) such as vaginal dryness, burning, discomfort with intercourse, and urinary frequency or discomfort. Some women experience none of these changes, while others struggle with many changes and symptoms during the perimenopausal period. For many women, this is also a busy and demanding time in life, whether related to a career, raising a family, or caring for aging parents. Women need and want to feel better, and many look for ways to more comfortably manage their perimenopausal symptoms.

There are a variety of approaches to the management of perimenopausal symptoms. Often, simple changes in a person’s diet, exercise routine, and lifestyle can make a positive difference. Women sometimes also find relief with the use of nutritional or herbal supplements. This may include the use of “phytoestrogens” which are plant-derived estrogens, such as black cohosh, Mexican wild yam, or soy products. Acupuncture is another modality which can be quite useful, particularly in treating the “vasomotor” symptoms, i.e., hot flashes or night sweats.

Some women opt for the use of hormonal supplementation during the perimenopause phase. This may mean the use of a low-dose oral contraceptive pill, or even the initiation of hormone replacement therapy (HRT). By supplementing a woman’s own physiologic production of hormones, women frequently feel relief from many of the symptoms related to hormonal fluctuations of perimenopause. However, HRT can be associated with health risks, so only after a discussion with a healthcare provider should HRT be initiated.

If you are interested in learning more about Perimenopause and Menopause, please join us for our monthly talks in our office during evening hours. Please call our office at 603-431-6011 to learn more about this special informational series.