Transitioning Through Menopause

Women with bleeding disorders have more to keep in mind, but symptoms are manageable
Author: Kadesha Thomas

It wasn’t raining, but Joi Heierling was drenched. While sitting across from a concerned parent trying to draft an education plan for a child with ADHD, a sudden hot flash struck. Sweat seeped through her blouse as her face flushed red. Then, her nose started to bleed.

“Are you okay? Are you sick?” the parent asked, wondering if the symptoms could be contagious. “No,” Heierling, 57, a former physician’s assistant who lives in Chicago, responded, pressing a handkerchief to her nose. “I’m in menopause, and I have a bleeding condition. Can we reschedule?”

As a woman living with type 2 von Willebrand disease, Heierling had experienced spontaneous bleeding episodes throughout her life. Her menstrual bleeding was so profuse that, after trying oral contraceptive therapy and other medications, she eventually had a hysterectomy at age 46 to remove her uterus and both ovaries. A month after the surgery, her body launched full force into menopause.

About 6,000 women in the United States approach menopause, often colloquially called “the change,” each day, typically beginning between 45 and 55 years old, according to 2010 data from the latest US Census and the US Department of Health and Human Services. Experts agree that women with bleeding disorders may have more to keep in mind, but fortunately most menopause symptoms are tolerable or treatable.

Menopause is the body’s gradual process of ending a woman’s ability to get pregnant, either naturally or after a hysterectomy. Estrogen levels taper off and the woman’s body no longer releases eggs for fertilization. It is officially diagnosed after the menstrual cycle has stopped for 12 consecutive months, according to the North American Menopause Society, a nonprofit organization of clinicians and researchers that provides information on menopause and healthy aging in women.

Before menopause, most women go through perimenopause, which starts at an average age of 51 and lasts from a few months to six years. During that phase, many women experience physical symptoms such as hot flashes and cold sweats, heart palpitations, low sex drive and vaginal dryness. Some women are prone to acne and experience rapid weight gain. Nonphysical symptoms include depression and anxiety, irritability and disrupted sleep.

Perimenopause may be a particularly difficult time for women with bleeding disorders, as menstrual bleeding becomes even more irregular and unpredictable. While most women have fewer and lighter periods during perimenopause, women with bleeding disorders can experience the opposite, says Andra James, MD, associate professor of obstetrics and gynecology at Duke University Medical Center. As women age, they are more vulnerable to gynecologic problems, such as noncancerous growths like fibroids or polyps, an overgrowth of the uterine lining called endometrial hyperplasia, or even uterine cancer. These conditions can also cause heavy bleeding. This means that women with bleeding disorders who are approaching menopause may need to consider a combination of treatments and lifestyle changes to curb excessive bleeding and relieve severe symptoms.

Breakdowns, Flare-Ups and Cure-Alls

Even though the Women’s Health Initiative study showed that hormone therapy increases the risk of heart attack, stroke, blood clots and breast cancer in women who are more than 10 years past the start of menopause, it is still a common treatment for younger women who experience early menopause or those with particularly severe symptoms.  Hormone therapy means taking two oral doses of hormones—estrogen, which alleviates hot flashes, mood swings, sleeplessness and vaginal dryness; and progesterone, which helps prevent the risk of uterine cancer. Women who have had a hysterectomy may not require progesterone and can usually take estrogen alone.

“In weighing whether to use hormone therapy, women need to consider their own risk factors, family risk factors and other conditions that would modify risk,” advises Barbara Konkle, MD, a hematologist in the Hemophilia Care Program at Puget Sound Blood Center in Seattle. Women with bleeding disorders also need to understand that their con­dition does not lower their risk of heart disease.

Other medical conditions precluded Heierling from using hormone therapy. The hysterectomy addressed the excessive bleeding, but she found that black cohosh tea, avoiding spicy foods and taking vitamin E helped alleviate some of her hot flashes.

Further, exercise and avoiding caffeine in the evening can help with sleeplessness; as can the use of mild sleep aids. A lubricant or a low-dose vaginal preparation of estrogen, such as the vaginal ring, a 2-inch-wide flexible ring that is inserted  monthly, can help with vaginal dryness. Antidepressants and a strong circle of support can help with mood swings. 

Other methods to reduce excessive bleeding include the levonorgestrel IUD, which contains progesterone to prevent the uterine lining from building up during irregular menstrual cycles, or tranexamic acid, a medication that neutralizes the body’s chemicals that break down blood clots. For people with bleeding disorders, this helps the blood clot normally, preventing prolonged bleeding. (See online article, “Contraception Helps Decrease Bleeding in Women,” HemAware, March 2009.)

Heierling says the best way to make a smooth transition through menopause is to make sure you have the right team. “Go to your hemophilia treatment center to have an all-inclusive, comprehensive consultation,” she says. Many are staffed by gynecologists who are familiar with the issues faced by women with bleeding disorders.