The Wisdom of Menopause

by Christiane Northrup

  What do I mean by heavy bleeding? Many women experience a heavier flow on the first or second day of their periods, which slows them down a bit, but I consider this within the realm of normal. (You may still wish to try some of the gentler treatments listed.) However, if your bleeding prevents you from leaving the house or participating fully in your life for more than two days per month, if you routinely soak through a couple of tampons and a pad all in place at the same time and then through your clothes or your nightgown, or if you’ve been diagnosed with iron deficiency anemia, you need to take action.

  The Wisdom of Bleeding:

  Are You Leaking Life Energy?

  I always ask women with heavy bleeding if they are leaking their life’s blood into any dead-end job or relationship that doesn’t fully meet their needs. Are you giving more than you are receiving in return? Is someone or something draining your energy by being a kind of Dracula? Take some time alone, sit right down on the earth, and pray for guidance and a boost of energy for yourself.

  Physical Causes of Heavy Periods

  In addition to hormonal imbalance, physical conditions may impede the normal uterine contractions that help stop menstrual blood flow each month.

  Fibroid tumors are the most common physical reason for excessive bleeding. Whether or not a fibroid causes bleeding depends upon its location in the uterine wall. Bleeding is most often caused by submucosal fibroids, which are located right under the endometrium, the mucous membrane that lines the uterus.

  Adenomyosis is another condition that can cause heavy bleeding. Adenomyosis results when the endometrial glands that line the uterus grow into the uterine muscle (the myometrium). When this happens, little lakes of blood form in the uterine wall that do not drain during menstruation. Over time, the uterus enlarges and becomes boggy, spongy, and engorged with blood, disrupting the normal uterine contraction patterns.

  Since both fibroids and adenomyosis are associated with excess estrogen, minimal progesterone, too much prostaglandin F2-alpha, and frequently too much insulin, hormonal and physical factors are often present at the same time.

  Treatment Choices for Heavy Bleeding

  Follow the Master Program for Creating Pelvic Health, later in this chapter. If you still need assistance, and you’ve had a physical exam and a Pap smear within the past year to rule out a more serious condition, consider the following options:

  ~ NSAIDS. Take a nonsteroidal anti-inflammatory drug, such as ibuprofen (Motrin, Advil), naproxen sodium (Anaprox, Aleve), or ketoprofen (Orudis), daily starting one to two days before your period, and continue it regularly through your heaviest days. Use the lowest dose that gives you results. The NSAIDs have definitely been shown to decrease menstrual blood loss because of their ability to interrupt excess prostaglandin F2-alpha.

  ~ LYSTEDA (TRANEXAMIC ACID). This new nonhormonal therapy introduced by Ferring Pharmaceuticals in 2010 has been shown to reduce menstrual blood loss by nearly 40 percent over three and six cycles of use—and women see results as early as their first cycle after beginning the treatment.1 Heavy menstrual bleeding is associated with an abnormally high rate of blood clot breakdown, and Lysteda works by inhibiting the breakdown of blood clots. The recommended dose is two 650 mg tablets taken three times a day for up to five days during the menstrual period each month. (For more information, visit www.lysteda.com.)

  ~ SYNTHETIC PROGESTERONE. When natural progesterone doesn’t work, it is sometimes necessary to use a strong synthetic progestin such as medroxyprogesterone acetate (Provera). (This is the only circumstance in which I recommend the synthetic.) This is especially true if you have a fibroid that bleeds and you haven’t been able to stem your problem with gentler approaches. Provera for heavy periods is prescribed at a dose of 10 mg once or twice per day for the two weeks before your period is due. Then you give your body a rest for two weeks and start over. Usually a three-month cycle of two weeks on and two weeks off will result in a significant decrease in excessive bleeding. Though Provera can have side effects, these are usually acceptable compared with losing your uterus.

  ~ BIRTH CONTROL PILLS. Many women who are having heavy, irregular periods due to fibroids, lack of ovulation, excess estrogen relative to progesterone, or a combination of these conditions often do well on birth control pills. Although they do not result in a true cure, they are a good option when the alternative is surgery.

  ~ D&C (DILATATION AND CURETTAGE). This standard surgical treatment for heavy bleeding involves scraping the uterine lining and removing excess tissue. It frequently decreases the problem, for reasons that aren’t entirely clear. It is often used also to diagnose the specific condition causing the bleeding.

  ~ ENDOMETRIAL ABLATION. In this surgical procedure, the lining of the uterus is obliterated with a laser or with cautery. Because the procedure destroys the endometrial lining, it often results in complete cessation of periods or very light periods. It should never be used by anyone who wants to maintain her ability to have children.

  Endometrial ablation works very well for many types of intractable bleeding and is usually done as an outpatient surgery. (NovaSure is one type that’s worked well for many women; see www.novasure.com.) The procedure should be done by someone highly skilled, with extensive previous experience. For a referral, consult a university medical center or teaching hospital. You can also call your local hospital and ask who does the surgery. Make sure the surgeon you choose is a board-certified OB-GYN.

  I’ve referred a number of women for this procedure. For some it provides great relief. One of my newsletter subscribers wrote to me: “Three months ago I underwent an endometrial ablation and tubal ligation. At age forty-four this sterilizes me two ways, for which I’m grateful, and has remedied the constant bleeding and clots for weeks on end. I now have no more periods! Yeah!” Though I don’t like the connotation of the word sterilize, I certainly appreciate her relief!

  MARTHA: Intractable Heavy Bleeding

  Martha wrote me the following about her midlife bleeding problem.

  I am forty-two years old. I weigh about 190 on God-given big bones, exercise regularly, and am generally healthy. My problem has been described as flooding. I have seen several doctors about this. They prescribed a double dose of birth control pills that I took for four months with no result. I have had a biopsy done, with negative results. My Paps are normal.

  My periods last twelve days and are very heavy with lots of clots. There is constant bleeding in between. I consulted a herbologist, who thought that because of my forty excess pounds, my fat cells could very well be overproducing estrogen. That is why the pill and the progesterone cream that I have used have not helped the constant bleeding.

  I have read Susun S. Weed’s book Menopausal Years: The Wise Woman Way. In it she suggests using homeopathic remedies such as lachesis. I am also drinking raspberry leaf tea and using shepherd’s purse. I am taking iron, as that has been low. Also Lactobacillus acidophilus, calcium, magnesium, and a good multiple vitamin.

  The bleeding still has not stopped. I am becoming pretty tired of all of this, and as you can well imagine, my desire for sex is low with me having to constantly wear a pad. The bleeding has been going on for four months. Do you have any suggestions that may help?

  I suggested to Martha that she seek help from an acupuncturist right away and also continue taking iron. I also recommended a Chinese patent medicine called Yunnan Bai Yao, which is superb for helping flooding problems. (See Resources.) It generally works within a week or two. I also suggested that she lose ten to twenty pounds, which could significantly reduce her excess bodily estrogen production.

  It is possible that Martha has an undiagnosed submucosal fibroid. The diagnosis is made with ultrasound, MRI, or with a procedure known as hysterosalpingogram, in which dye is injected into the uterine cavity under X-ray visualization. If this is the case, she may need a surgical approach such as endometrial ablation or fibroid removal done via the vagina. I’ve also seen her type of problem respond we
ll to a D&C done in the operating room.

  The main point here is that there are many, many approaches to controlling heavy bleeding during perimenopause. In every case, it’s helpful to have a diagnosis and treatment plan with alternatives to hysterectomy. Here is the bottom line: Every perimenopausal woman who is experiencing heavy bleeding needs to know that there are many safe and effective treatment options. Hysterectomy, which amounts to killing the messenger, should be a last resort.

  FIBROIDS

  Benign fibroid tumors of the uterus are present in 10 to 20 percent of women in the United States, and in 20 to 40 percent of women older than thirty-five. They occur in women of all races and backgrounds, but they are more common in women of African American or Caribbean descent. Fibroids arise from the smooth muscle and connective tissue of the uterine muscle itself. Though they can occur in women as young as their late teens or early twenties, they are most often diagnosed when a woman is in her thirties or forties.2

  The majority of fibroids do not cause any real problems. In other words, they are just there. Sometimes, depending upon their location, you will be able to feel them. They feel like a smooth lump in your lower abdomen, just above your pubic bone. Because the female pelvis can accommodate growths the size of a newborn baby, it is obvious that small and even large fibroids don’t necessarily lead to any problems. In other words, you may not even be aware that you have one unless you have a pelvic exam or pelvic ultrasound. Your periods may not be any different, and chances are you won’t experience any pain or other symptoms. Fibroids may grow dramatically during perimenopause because of estrogen dominance (their growth is stimulated by estrogen), but they often shrink just as dramatically after menopause—nature’s treatment.

  FIGURE 12: TYPES OF FIBROIDS

  The Wisdom of Your Fibroids

  Though there are well-established dietary and hormonal reasons why so many women have fibroids, the baseline energetic patterns that result in fibroids are related to blockage and stagnation of the energy of the second emotional center. Women are at risk for fibroids (or other pelvic problems) when we direct our creative energy into dead-end relationships that we have outgrown. When my own fibroid appeared at age forty-two, for instance, I knew that it was related, in part, to my staying in a one-on-one direct patient care practice for several years longer than I really wanted to. I was afraid that I wouldn’t be respected as a “real” doctor if I wasn’t doing surgery regularly and maintaining a full office practice. Though I longed to channel my creativity into more writing and teaching, I also feared my colleagues would resent me if I worked only part-time. This is the classic second-emotional-center double bind. Our simultaneous ambition and need for love and approval create a logjam in the creative center of our bodies that, under the right circumstances, becomes a fibroid.

  ELLEN: Birthing Her Creativity

  Ellen, thirty-eight, was married with two children and worked as a research associate at a local university. She loved everything about her job, from the subject matter itself to the people she worked with daily. She was proud of the fact that her colleagues sought her out when they needed help with their own projects. But as the years progressed, Ellen found herself drawn to working more independently. Unfortunately, because she had become “indispensable,” it was very difficult for her to set those other projects aside to birth her own individual creation. Her fibroid tumor was diagnosed at about this time.

  Over the next several years, her fibroid continued to grow as she found herself torn between the needs of her own particular research and the needs of her colleagues, children, and husband. During an office visit in which she consulted me about possible surgery for the fibroid, I asked her to consider where she was “leaking” her energy. She said that a large part of her identity and sense of self-esteem came from being there for others. She told me that if she was to go off and work by herself, she was afraid that she wouldn’t feel as useful—and that others would think she was selfish. As we talked about this, she realized that she had to make some long-overdue changes in her schedule and in her priorities. Then she told me that she wanted to give herself another six months before having any surgery.

  The next time I saw her, her fibroid hadn’t grown any further and was even a bit smaller. But more important, Ellen had told her colleagues what she was and was not willing to do for them—and had simultaneously made some big steps toward pursuing her own projects. In other words, she had started to birth her own creativity.

  If you have or have had a fibroid, ask yourself the following questions: “What are the creations within me that I want to put out in the world before I’m no longer here? If anything at all were possible, what would my life look like? If I had six months to live, what relationships would I release from my life immediately? What relationships would I give more of my time and attention to? What relationships truly feed and nourish me? Which ones drain my energy?” Write your answers in a journal. Discuss them with supportive friends. Deep within you, you have all the answers you need. You just need to be open to hearing them.

  Treatment of Fibroids

  Fibroids respond well to the suggestions outlined in the Master Program for Creating Pelvic Health, later in this chapter. After all, the first thing to consider is that a fibroid usually doesn’t need to be treated at all. A watch-and-wait attitude is perfectly reasonable in many cases; you can live with fibroids for years with no adverse health consequences if they are not bothering you. What may well bother you, however, is simply knowing that you have them. Given our cultural inheritance about our pelvic organs, the perception that something will go wrong is often a bigger risk to a woman’s wellbeing than the fibroid itself.

  It would do most women a world of good to lighten up about their fibroids. At the time your fibroid is diagnosed, you usually will not know what has caused your second-emotional-center imbalances. Understanding comes retrospectively. Instead, commit to learning from the process, whatever course of treatment you decide upon.

  An essential element of this learning experience is to release self-blame. It is never helpful to hold the idea that you have a particular illness or symptom because you are “doing something wrong.” If you knew ahead of time what the condition was trying to bring to your attention, you wouldn’t have had to manifest it. And in fact, all physical conditions have genetic, dietary, environmental, and emotional components simultaneously.

  Of course, there are times when you may wish to seek treatment for a fibroid. Though most fibroids will shrink after menopause is complete, you may not want to live with a growth that makes you look pregnant until that time comes. If you find, as I did, that you are dressing to disguise your fibroid, and your menopause is six or more years away, then you may want to take action. And, of course, if your symptoms include pain, heavy bleeding, cramping, or backache, you’ll definitely want relief. Thankfully, the treatment options are extensive.

  Nonsurgical Treatments

  ~ BIRTH CONTROL PILLS. Birth control pills are a combination of synthetic estrogen and progestin that can smooth out the estrogen dominance that so often causes fibroids to grow or become symptomatic. Because they consist of synthetic hormones, I’d suggest that they be used only after more natural approaches such as dietary change or acupuncture and herbs have failed, or in situations in which a woman is unwilling or unable to try a more natural approach.

  ~ ELLAONE. Approved by the FDA in 2010 as a “morning-after” emergency contraception drug, ulipristal acetate (trade name ellaOne) has also been shown to shrink fibroids and reduce heavy menstrual bleeding. Ulipristal acetate is part of a new class of drugs called selective progesterone receptor modulators, which block the hormone progesterone. Blocking this hormone delays ovulation, preventing pregnancy. But because progesterone also feeds fibroids, they shrink in the hormone’s absence. That means ellaOne (manufactured by HRA Pharma and available by prescription only) is effective in treating fibroids while still preserving a woman’s fertility.

  ~ GNRH AG
ONISTS. GnRH agonists such as nafarelin (Synarel) or leuprolide (Lupron) act at the level of the pituitary gland and put the body into a state of artificial menopause. This lowers estrogen levels and shrinks fibroids. Side effects include all the symptoms of late perimenopause, such as bone loss, hot flashes, and vaginal dryness, but these can sometimes be effectively countered with low-dose hormone therapy that doesn’t cause fibroids to grow.

  GnRH agonists can be quite effective as alternatives to surgery for some women. I do not recommend them if you have a family history of Alzheimer’s disease, because the rapid withdrawal of estrogen from the brain may not be advisable in susceptible women.

  Surgical Treatments

  ~ MYOMECTOMY. Fibroids can often be removed surgically. The size and location of a fibroid will determine the surgical route. Fibroids that are located just under the uterine lining deep within the uterus, for example, can sometimes be removed vaginally. Others can be removed via laparoscopy (sometimes known as belly-button surgery). Large ones, such as the one I had, usually require abdominal surgery.

  If you decide to have your fibroid removed surgically, the procedure should be done by a pelvic surgeon who is trained in the repair and preservation of the pelvic organs and who philosophically is aligned with your desire to keep your uterus. When he was finished with my surgery, my pelvic surgeon told me, “Well, I’m happy to report that you now have completely healthy and normal pelvic organs. I didn’t have to remove a thing except the fibroid!” That’s exactly what I wanted to hear.