How much uterine bleeding is too much uterine bleeding?
How do people know when to seek treatment? At what point is it ok to tell a medical professional there is something wrong or to ask for treatment options? What about society might dictate the course of this topic for both patients and providers? What if patients fear being told, “It’s not a big deal, 4 of the 5 patients before you have it far worse”. Should they wait until they lose a big project, or their job, due to bleeding through during meetings? Or until they bleed through at the grocery store and have to leave the full cart where it is to try to escape as unseen as possible? Do they wait until they’ve missed 4 social engagements due to excessive bleeding, or 5? What is the magic number that shows they’ve tried to tough it out, but now it’s unreasonable? So often people hold back either because someone has already told them “it’s normal” or because they fear what they may be told – perhaps they fear the diagnosis, maybe they fear the treatment. Or perhaps they hold back because “Mom (or Grandma) had it so much worse, and they never complained,” so they keep believing it’s fine. What is it about gynecology, vaginal bleeding in particular, that creates such a gray area? Why do people find it difficult to seek treatment or receive a proper diagnosis (for example, the average diagnostic delay for endometriosis is 7-12 years)?
To begin to understand the social context that has framed our understanding of uterine health, we need to take it back, all the way to ancient Greece. For far too many years, numerous maladies have been blamed on the uterus. This idea is traced back to the late fifth-early fourth centuries BC and from a collection of writings known as the Hippocratic Corpus. It was thought that the uterus was a wandering organ and was the origin of female diseases. Hippocratic authors have named many reasons and solutions for this wandering, but ultimately the only cures were sex and pregnancy. Some authors noted that lack of irrigation from male seed caused the uterus to become dry and light and travel upward, causing “hysteria.” The diagnosis of hysteria was commonly used to explain the dreaded female ailments of erratic behavior, fainting, headaches, and mood swings.
Interestingly, the word hysteria is derived from the Greek word “hyster,” meaning womb. And the phenomenon of hysteria is what Aristotle used as the rationale for why women should not be allowed to be educated or in politics. Thankfully, we are no longer in these times for those of us born with a uterus.
However, although we have learned much, and many things have changed, much about our understanding of the female body remains unclear or feels complex. This lack of clarity creates the opportunity for bias and judgment to cloud medical care. Along with the social expectations for the female sex to be selfless caretakers, the lack of clarity also creates a perfect scenario for those with excessive uterine bleeding to stay quiet. People don’t want to complain or bring attention to themselves. This creates all the reasoning they need to continue to soldier on without seeking treatment.
When treatment is sought, we rely on medical algorithms to tell us what and when to treat. For example, normal menstruation patterns define flow volume by what the patient considers normal, yet we typically ask patients to describe how much flow they are experiencing. What if we were to ask them if they considered their flow light, normal or heavy? How do they know what qualifies as light, normal or heavy?
This post is not about quantifiable medicine. We can look those parameters up on Uptodate. This post is about people, their lives that are different from ours, and the things that make living that life difficult. If someone were to tell us that their bleeding is too much, too heavy, it is up to us as medical providers to quantify as much as possible and determine other potential risk factors, and to help reduce the bleeding. It is up to us to determine best treatment plans based on the particular person’s life who is currently sitting before us. It is up to us to create an algorithm that works for that person versus staying bound by the algorithm in the medical textbook. It is not up to us to tell them that their bleeding is heavy due to stress, body weight, age, medications, and then to leave it on them to change these (sometimes unchangeable) things. I have had far too many patients tell me that they have been told they need to lose weight before anyone can do anything to treat their bleeding – these same patients have been experiencing excessive bleeding for more than 20 years because they have been unable to lose the weight expected of them. It is up to us to do better, to work with our patients versus dictate to our patients. Once we are able to work within that scope, true healing can begin for our patients.
See Nisha McKenzie speak at a 2022 Skin, Bones, Hearts & Private Parts CME Conference. Click here to read more about Nisha McKenzie and where you can see her live and in-person!
Nisha McKenzie is also apart of our Master Clinician Series, to view her recorded webinar from November 2021 click here.
Nisha McKenzie, PA-C, CSC, NCMP, IF
Affiliate Clinical Professor | Grand Valley State University Physician Assistant Program
Teaching Faculty | University of Michigan Sexual Health Certificate Program