85: Heavy Menstrual Bleeding with Dr Talat Uppal

Welcome to Dear Menopause podcast, where we discuss the menopause transition to help make everyday life a little easier for women. Hi, my name is Sonya and I am your host Dear Menopause. Today, I have a very special guest with me, Talat Talat. is an obstetrician gynecologist specializing in heavy menstrual bleeding. This is an area I did not know a lot about, so I found our conversation absolutely fascinating. If you're a woman and you menstruate, this is an episode that you will find absolutely fascinating. Talat, welcome to Dear Menopause.

Thank you so much for this opportunity, Sonya, and what wonderful work you do.

Oh, thank you. Now. Today we are going to have a juicy conversation about menstrual bleeding, but your speciality is heavy menstrual bleeding, so would you like to give us a little bit of an intro on who you are and the work that you do?

Thanks, sonya. So I'm a gynecologist that's based in the northern beaches of Sydney and I have an interest in clinical education as well, particularly general practice and primary care based education, because I think they do amazing heavy lifting in women's health space. I also am trained in ultrasound and I have set up an organization called Women's Health Road, which is a medical center, sonja, and it's located opposite the northern beaches hospital and it's like a collaborative multidisciplinary team. So we're kind of a little bit more holistic in our approach and we value, for example, mental health or the expertise of physio or allied health. So it's quite a well-rounded team. And, like you mentioned my interest, my primary interest is management of women with abnormal bleeding and particularly heavy menstrual bleeding.

I love your multidisciplinary team. I think it's absolutely wonderful to think that we can have a model for healthcare, particularly for women because that's where my passion lies that does offer so many of the services that can be so hard to go out and find, because I know you've got Penny Hanlon working with you as a physio and Penny is amazing at women's pelvic floor health as a physiotherapist and it can be really hard for women to find a physio that does specialize in women's pelvic floor health. So to have a kind of this one-stop clinic where women can get, like you say, the mental health support, the physio support, I think you've got at least one great. GP on board as well. Yes, I really, really hope that this is a model that we can see rolling out across the country for more women. So thank you for setting that up.

Thank you, sonya. I agree that these are the standards that women deserve and should access, and I have honestly learned so much from my peers. I think that those days of justice specialists with 40 patients and just one person seeing a long gone, the future of health is collaboration, and we all bring a unique skill and talent to that adds to the women's journey if she wishes to reach out. And what I like about such models is that it allows women to decide well, what part of my health care that I'm being offered is more important for me to prioritize and what package should I individualize for me as a person.

Yes, so important to put that patient front and center. I love that so much. Okay, so onto our topic. Can you give us a description and an understanding for someone like me that has never experienced heavy menstrual bleeding? What defines heavy menstrual bleeding over what I would consider a normal period?

So excellent question, sonya. There are two concepts. First of all, heavy menstrual bleeding is basically we need to sort of gauge it against quality of life in the first instance, and quality of life for women. Sonia has been so undervalued for so long really and quality of life, as you well know, is a very broad spectrum of facets. So it includes her physical well-being, it includes her emotional well-being, it includes your social well-being and it also includes your material well-being. So there's a productivity issue when we're talking about heavy menstrual bleeding, because we all know women who are either unable to focus at work or have to take time off, etc. So that's one way of looking at it, which, if these periods are affecting me in some way, then it is a problem, and the other way, obviously we need to have some flags or what could guide us, or what are the clues that these periods may be heavy. And these could include look, am I passing clots that are, for example, bigger than 50 pieces? Am I changing my sanitary protection every one to two hours? Am I having to wake up at night to change my sanitary protection? Am I having to use multiple types? So women tell me they've used two or three different types of sanitary protection. That's not normal, wow, they claim. Or have I had episodes of flooding through my clothes, which can obviously be very embarrassing? Or, sonia, because they're having such heavy losses, then women may become iron deficient or may become having, may have anemia, and so then they would get dizziness, tiredness, profuse tiredness sometimes, and they might have palpitations. So you get another cohort of symptoms that are actually because of the losses that they have had.

I wonder if you will be able to confirm this. There are women that experience heavy menstrual bleeding or menstrual bleeding that's outside of the norms, but they don't know that it's actually not normal, because that's the only thing they never know. We don't talk about our periods. We don't necessarily have conversations about menstrual bleeding to say, hey, this is what you should expect if you're experiencing this. That's not normal, seek some help. I wonder how many women you come across that have been experiencing this and not sought help for it.

Sonya, this is my weekly reflection, because every week I sit down and I think, oh and you can imagine, sonya, that I work in northern beaches Often women I'm caring for are taking really proactive ownership of their health. They're worrying about their diet, taking care of their exercise regime, but still I reflect that their health literacy, for many women that I look after, is actually quite basic when it comes to menstrual health, and I know that there's that concept around 28-day, 5-day periods. But there is a variation in normal and I think, like you rightly pointed out, there can be a big struggle and trivialization of symptoms, and so we kind of do say look, if your periods are lasting longer than seven days, but then some women are bleeding so heavily, so because those two, three concepts of are your period cycles coming around more frequently, which often happens at the start of perimenopause is the volume heavier, or and or, and these are all and or situations, because obviously if she's bleeding for more than seven days, then she's going to bleed more volume and so therefore, that's heavy as well. So I think that there is constantly trivialization or minimization of symptoms by women and I feel that they're just resilient. We women are just so resilient, we're used to juggling so many things, we just used to putting up with things, and so that sort of philosophy carries on in menstrual well-being and they just say, oh well, you know, this must be normal. And then, sonya, it's not just the women themselves, unfortunately, even though we have excellent clinicians and I think that a lot of clinicians do amazing work Unfortunately there are people, when women go to them as clinicians, who will just say, oh, they're there to go away or will sort of reassure them but not actually proactively offer them the full suite of management options that are available. And then, third level of normalization of abnormal periods is by society. So they might have an auntie that says, oh, hang on, I also had this, and then, you know, it finished by the year. So, hello, it finished after menopause and this person is only 42. So we have basically condemned her to a decade of suffering, a potential decade of suffering. So I think those are the concepts where we are wanting to raise awareness so that women can actually say, hey, hang on, maybe what's going on with me is not quite right and there is a lot of management options. I think, sonya, that's the other thing that bothers me. Is that because it's a problem not with one solution, with so many solutions and because I also see women, obviously at the other end of the treatment journey, and our most common feedback is why didn't I have this earlier? Why did I suffer so much?

Wow, that's really heartbreaking to think that. I mean, it's great that obviously you are able to take your patients to a place where they're healed and they're not experiencing those abnormal periods anymore, but it's really heartbreaking to think that there are obviously so many women out there that get themselves to that position in the first place, whether that's by cause of their own lack of knowledge or a support of a clinician that hasn't been able to get them to a place where they needed to be. So then let's talk about what those options are for women that perhaps are listening, and a kind of going hang on a second. So maybe what I've been experiencing isn't normal, but I should maybe see someone.

There are a number of options and obviously they need to be tailored to the women's preference and also to certain risks that she may have in her journey, in her health journey. So usually if I see a woman before I go into options. I'm actually thinking look, why is this woman bleeding heavily? And so we're thinking through look, is this a structural cause in the uterus itself, Like, for example, is the uterus having a polyp? These are like fleshy chandeliers in the uterus. Most of them are benign. Or maybe she has fibroids, or maybe she has a variety of endometriosis that's called adenomyosis, in which the wall of the uterus has the lining, and so that makes women bleed more heavily than usual. And a tiny number, sonia, are actually harboring a cancer or a pre-cancer. And if we're going to look at statistics, sonia, it's about one in 44, the lifetime risk for women and sort of. If you compare that with breast cancer, which is about one in eight women, is actually a rarer, it's less common, but obviously women that are bleeding abnormally are more likely to have it. So, again, you know, therein is the importance of making sure that, even though something might be rare, it is important to rule that out. And then, outside that, you can have external factors that are making the woman bleed heavily, like, for example, just a lack of an ovulation, and this happens in the ends of reproductive life, so, for example, in adolescence and in perimenopausal women, and that can predispose this. At times it could be a blood related issue. That is, a more generalized issue and you ask the history and these women have had you know like, for example, they bleed more at the dentist as well. So it's a more generalized and also affecting the uterus. So there can be a number of causes, and so the first thing I try and do is try and establish well, is there an obvious cause? Because the cause also sometimes guides the management. So certain options wouldn't be suitable for women, for example, let's say, with massive fibroids I might refer to another thing. So, not only to try and give her answers, but also to rule out something really nasty like a cancer or a pre-cancer, but also to help us tailor management. And this is a space, sonia, that's really meant to be shared decision making. So it's meant to be. We do want women to articulate, so I appreciate it when someone says, hey, look, I don't really like hormones or I'm worried about going to theater, I don't want to go for surgery. So even though sometimes I find, after we share information together, people do change their minds and sometimes they say, oh well, actually, you know what, I don't mind that option, I might actually take that, and so it's really important to, but it's really important to articulate not only the fact to help diagnose it there is an issue, but be really active in the in, in what sort of management plan you feel is best for you. So in terms of the actual options available, there are certain tablets. There's one called trinexamic acid and also a, a, a common drug that is known as Ponston, which is methanamic acid. This combination can be for women that want to just sort of banded the situation. They want to just use it during the time that they have a bleeding and the one sort that out. They really do not want anything more elaborate than that. So the next tier up, or generally one of the most effective options, is what is popularly known as myrina, which is a progesterone based intrauterine device and so that can be inserted, sonia, and basically gets a lot of traction on the heaviness of the cycle. Now sometimes women can have irregular cycles, so one may move from a really heavy cycle to one where they are actually spotting for quite a while, especially in the first four to six months. So there can be some patients required before. Sometimes the myrina often is in research settings. When those pads have been weighed, women have actually bled less, even when it's spread out. But some people might have, you know it might might find that quite a resistance value, that now they're actually bleeding more days. So that's one thing to consider. And the good thing about myrina, those, sonia, is that it offers you contraception, which is also a need of us, of the perimenopausal women, for some patients. And also, once we have figured out what's going on we're sure there's nothing like a pre-cancer or cancer going on. We've sorted out if the woman prefers to have a myrina or a levina gestural IUD as its cause, she may choose to have that as part of a hormone therapy you know vehicle. So that could be the progesterone equivalent for her. So it's kind of taking three boxes for that person no-transcript if they need contraceptive support. And then the next level up there is basically going to theatre and we may also need to go for surgery for diagnostic reasons. So if they have a high quality ultrasound and it shows, for example, that there's some concern about the lining and we're worried about the potential of cancer, if we can say, we may elect to go to theatre for that reason. So some sort of some patients might be recommended to have a biopsy of the lining but in theatre. We can offer low risk, minimally invasive, lower tier of surgery, which is like an ablation, or certain fibroids or polyps can be removed from the inside of the uterus if they're contributing felt to be contributing to her clinical situation and, in the last resort, or for some women that might have a massive uterus or concern around malignancy, a hysterectomy could be the best fit option for them. Or for the person, sonia, who has gone through all these layers of options and hasn't actually gotten anywhere, still bleeding heavily, which is a very tiny minority of women honestly, majority of women are actually even I wouldn't say fixed, but they're moved to spaces which are far more comfortable. So obviously not all of our patients stop bleeding, but even some of our patients just move back to what a normal period is, and so for them, because they've been used to such torrential bleeding. They're like so grateful. They're like, oh, I just have a normal period, that's fine, that's okay, that's nothing, that's a piece of cake. You know, it's really very relative, isn't?

it? Yeah, it is, and it's fascinating for me as someone who has never experienced any abnormal menstrual issues at all. So I've heard words like ablation and I mean, obviously I'm familiar with hysterectomy, but yet to understand that there are so many options available and you can start quite minimally, I guess, with the medication, everything doesn't mean you have to go to surgery.

Absolutely, and sometimes the surgery I think women have amorphxated on hysterectomies but don't always, like you said, appreciate ablation, or there's another condition called nutrient embolization and radiological context that's an option as well. So, but like the ablation, Sonia, it takes like literally less than two minutes. The actual procedure obviously setting up, going to sleep and all that takes much longer, but the actual procedure takes me less than two minutes to do and I think this woman has suffered for four years for want of like. It's a day surgical procedure for some women who are suitable I'm not everyone is suitable or will opt for that but it really is life changing.

Yeah, I can imagine. I can only imagine how life changing it must be. Are there also lifestyle factors that come into play with this as well, where women can make adjustments in their life? Like you know, stopping smoking is something that can make a big impact for women.

So I think, sonia, look in general, obviously a good diet, particularly iron rich diet, because we are often battling significant losses in these women and they're often quite in negative balance, and that recognition that they may not be anemic but if their iron stores are low, that's an independent risk of getting tiredness and exhaustion and symptomatic. So obviously, from that perspective, a good diet would help to minimize that. But, to be honest, the kind of flooding that some women are facing, you know how much you know eat, or even orally, there's certain limit that your body will absorb and so we are having to give IV infusions. But that's also amid, sonia, that sometimes women say to me I was like, okay, what treatment have you had? And I've had two or three, I've had an iron infusion every six months and I said that's not really a treatment that is actually replacing your losses, and so I think that also needs to be clarified, that it is part of the management plan. It's not actually fixing the problem. Obviously, in general, especially women battling perimenopause, we always encourage them to minimize triggers for other things, because what I find, sonia, and actually my, you know, interest in menopause was because I love looking after women with abnormal bleeding and so what we would do is we would try and find a cause, we would try and stop or reduce the tap, we would try and make sure they didn't have cancer, we'd replace their iron. But I still felt there was something missing, without you know that, addressing the perimenopausal other symptoms. And so because we had a questionnaire that sort of said look, are you experiencing hot flashes, you're getting night sweats, what's your sleep like? What is your vaginal dryness? And so because we were proactively asking in that tool, I was then finding oh okay, although she's come to me for bleeding, but actually she's ticked these three other boxes, and so I think if we hadn't asked, it may have been so the heavy bleeding has been so overwhelming it may not even have been uncovered at that point. And then that made me think, actually you know, there's more role of actually having a menopause based discussion as well, in more detail than just, you know, worry this or something that's basic like that. So I agree that there's support for that, but I don't know that there's a lot that we can do that would necessarily minimize the bleeding itself, especially if there's a structural cause like if an early cancer or something I don't know that there's any diet or exercise that could reverse that.

So if a woman is listening today and she is really resonating with some of the things that we've talked about and she goes off to see her GP or her clinician, what are your top tips for her? Having a conversation with someone about this?

So first of all, I would encourage her to be quite confident and to share that she has what she feels is a problem and this is why and that she's here to seek a solution and a management plan. So ideally, women who have heavy bleeding should then be guided to some blood tests and be encouraged to have those. We obviously need to, sonia, make sure that someone's not pregnant without knowing that, and we also want to make sure that we're not. You know we're checking, like we've mentioned multiple times today, anemia and iron studies. We also would like to do an ultrasound. For most patients they married an ultrasound. The GP should be volunteering that and most GPs, I must say I quite would at that sort of. It's more around the actual treatment options that and we have a lot of sympathy because GPs are also quite time-poor, we know. So it's a very, very complex space that you know. It's not that anyone's deliberately not trying to help is, I think, more that the woman and it's unfortunate for us to say that because the women that should drive this but a lot of good change for women have come when the women themselves have demanded good care and they have said, look, I need the options. I've actually read about these and a number of patients now are saying, hey, you know what I'm actually thinking of having another baby, so for me and my arena might be a good fit. How can I get this organized? So the discussion is starting at a more mature level than saying I'm actually bleeding heavily, what do I do? I always find that it's helpful when women have had some information about heavy menstrual bleeding options, because we very much value their opinions and their preferences and so once they see their GP they can actually institute very solid primary care options and a management plan. And really the recommendations are that you know if six months are not working of various options, then refer to our gynecologist. Or if their concerns around you know like we've mentioned, concerns around malignancy, or you know if it's a massive uterus with fibroids or certain very obvious gynecological pathology, so those women should be triaged earlier, or if we find we're not winning. So I don't expect patients to be bleeding heavily for six months before they see gynecological care. But the GPs have a very solid primary care role in supporting the patients and I think more and more awareness is leading to more and more clinicians actually doing that.

Yeah, fantastic, great advice. Thank you so much. And you mentioned that you have some resources that we can share in the show notes.

If I were to say there's a quarter of women have heavy menstrual bleeding. Let that sink in. Wow, 25% of us. And I also wanted to mention that there was a recent online survey by Hologic, and this was carried out by an independent research company called Two Blind Mice, and 5,000 women participated Sonia, they were. Basically the plan was to try and figure out what are the attitudes to this under-recognized condition, and no surprises we saw that 9% of women were actually saying they always have heavy periods. 19% of women, sonia, said that they often have heavy periods. Three quarters of women had had heavy periods at some point in their life. So we were still somewhere above that one quarter number, where women are often having heavy periods, or always, and more than half of women were yet to see a medical doctor. So that was this is in these days. And then, basically, the other thing that came out was that 69% had had some embarrassing episode, and we know that it can be quite awkward for women if they flooded work, or we know there's so many women that don't go swimming or different sort of activities that they refrain from. But the most interesting statistic to me was that 92% of women want more conversations, sonia, and so thank you for this morning, because this is exactly what the women have asked for. We have recognized that there's shame, there's taboo, there is so much secrecy around menstrual health that needs to be changed and, like I mentioned earlier that this is custard to adolescence as well, and it's so heartwarming for me when women bring their daughters and they say we didn't get an opportunity to talk about our gynecological or our payment and causal concerns. We are doing different for our children.

That's awesome. It's sad that the mum had to miss out, but it's great that there's that. You know not wanting to pass that baton on as such to their, to the next generation, so yay for women that are doing that. That's fantastic. And that survey, those statistics, wow.

They're really shocking and it is just sad to see that, like I said, a space with so much support. But again, basically, when women were asked why they haven't seeked care, the first one was that they had deprioritized themselves. And I hear this every day, sonia women are caring for their elderly parents, for their children's issues, for even their work related people telling me that, oh no, I have this deadline at work and I'm thinking but you're not functioning well. You're telling me you're so tired you're not able to focus. So it's sad and you know the joys of perimenopause. Imagine that layer over, that has a ferritin of four or has an external iron and is then anxious. I think the emotional side of perimenopause in itself can be very overwhelming and then if you layer the misery of bleeding heavily, the hygiene issues, the quality of life impact, it's just a very negative space that we need to actually support women to come out of that cycle?

Yeah, absolutely. Now I do have a question around. If someone's listening to this, and you know, one of the things that I find so frustrating for women in Australia is you know you and I sit here in a city. We have great options available to us to seek, you know, support from multiple GPs. We have, you know, multiple gynecologists to choose from. If someone's listening that's in a more remote or regional area, what are their options if perhaps there's not a gynecologist in town? And you know, I know, that we have telehealth services for some healthcare. Is there some telehealth available around? You know, gynecological care?

So we have set up at Women's Health Road, basically a national option, so it's a hybrid care model. We are happy to have telehealth from anyone and we're happy to connect with that person's general practitioner to then sort of work in partnership with them and to support them in trying to you know, see identifying, you know where's your nearest public gynecology clinic, for example. If things are not being sorted out at that level, certainly we are offering that. Sonya. Some of the other directions our practices embarking on is we're trying to request for a international heavy menstrual bleeding day for a condition that affects a quarter of women. I am a bit grieved that we don't have a day for this, so I think that that would be a way of raising awareness for everybody. And then we're also trying to look at some digital technology, and the great thing about digital technology is not about replacing the clinicians, it's about empowering the patient to be able to sort of, you know, at least get some degree of support, that which is not necessarily in breaks and geographically, you know, restricted. So that is one of our agenda for 2024 to be able to roll out a program that encourages a digital support for women and that makes some of their journey easier and less dependent on the actual local availability of resources.

Yeah, fantastic. Tell that you are doing amazing work in this space and I'm so grateful on behalf of everybody listening.

Oh good, Sonya, Thank you so much for the time today and I really appreciate that amazing work you do with Dear Menopause. It's such amazing advocacy.

Thank you, teller, I appreciate that and thank you for your time today. Thank you for listening today. I am so grateful to have these conversations with incredible women and experts and I'm grateful that you chose to hit play on this episode of Dear Menopause. If you have a minute of time today, please leave a rating or a review. I would love to hear from you, because you are my biggest driver for doing this work. If this chat went way too fast for you and you want more, head over to StellaWomencomau slash podcast for the show notes and, while you're there, take my midlife quiz to see why it feels like midlife is messing with your head.