Heavy Menstrual Bleeding While on a Blood Thinner

Arielle Langer, MD, MPH: Thank you again for having me here, and I’m excited to share this information. I run our Women’s Bleeding and Clotting Disorders Program at Brigham and Women’s, and I’m dealing with this topic all the time. And so, knowing that we can’t get to everybody’s individual story, I want to start by talking about classic examples of what might show up in clinic dealing with the difficult issue of heavy menstrual bleeding or heavy periods in the setting of blood thinners. I want to give two examples of the kind of thing that a lot of people may be experiencing to ground us as we move forward. 

First is a 43-year-old woman who was recently diagnosed with an abnormal heart rhythm called atrial fibrillation – and a stroke is the way it was diagnosed and a complication of that heart rhythm problem. She was asked to start warfarin—I’m going to try not to use brand names for a lot of reasons here, but since folks are more familiar, the brand name is Coumadin and now Jantoven^®—to prevent further strokes. Obviously, the stroke itself is super difficult in this scenario, but trying to return to a sense of normalcy after recovering from that hospital stay has been really difficult because her periods are so heavy that she has to leave work meetings abruptly to change a pad or risk bleeding through her clothes in public. And so, this has been really intrusive for her. 

Another example is a 28-year-old woman. She had a blood clot in her lungs—called a pulmonary embolism—after being started on birth control pills, which were started because she already had heavy periods. She starts on a blood thinner to treat that pulmonary embolism—rivaroxaban, brand name being Xarelto^®—and stops the birth control pills because they were thought to be part of the cause of her blood clot. Now, she was already dealing with heavy periods before even starting blood thinners and is very worried that they’re going to get even heavier. She is now avoiding going out with friends or any activity where she might not have continuous bathroom access.

So, some of these scenarios might resonate people or they might be a little bit different than what you’ve been going through yourself. But I want to keep these ideas in mind—of what I’m taking care of all the time—and want to set our agenda today before we dive into individual questions. So, we’re going to move through a set of definitions. I always say, when I’m teaching our med students and residents and all levels of people learning to be doctors, that nobody got taught in their middle school health class what a heavy period is, so we shouldn’t assume that our patients know, let alone our colleagues, unfortunately. So, I’m working on that on the education side. But for all of us, we want to start there. 

We’ll go over some reasons to be on blood thinners because it helps us understand a little bit what some of our choices might be, moving forward, to deal with the bleeding. We’ll talk about impacts of blood thinners on the rates of bleeding, some of the consequences of heavy periods, as well as the lab tests that should be going on for monitoring, and then some strategies, some actual action items, as well as what you can bring back to your doctor. Since, of course, I can’t talk to you about your individual case, we want to make sure everybody leaves feeling a little bit more comfortable knowing how to use their time at their doctor’s visits.

So as mentioned, what is a heavy period? You might hear a lot of us who are in medicine saying “menses” or “menstrual period,” but I’m probably going to say period the rest of the time because that’s what we usually say when we’re outside of a medical visit. “Heavy” has several different definitions, and you don’t have to hit all of them to be there. But classically, since I don’t expect anyone here to have learned this officially, we say that heavy bleeding is. anything longer than seven days, anytime your pad tampon or whatever else you’re using for your period can’t last for at least two hours, and/or passing a clot bigger than a quarter. Not everyone uses these definitions, though, and some sources will also talk about things like a gushing sensation, like you can feel the blood flowing, or bleeding through clothes or things that indicate that you have difficulty controlling the blood flow.

With these different considerations, what I would say is while this is the official definition of what a heavy period is that we use in research and other quantification, if your period’s intruding on your life, it’s too heavy. And so, I don’t ever use this as a way to tell people to just deal with what they’re going through, that it’s not officially heavy. But this can also really help people understand. Since periods are not part of normal dinner table conversation in our culture, a lot of folks just don’t really have a sense of where they sit on the spectrum and might not realize that the bleeding they’ve been dealing with is actually very heavy. 

So, in terms of blood thinner uses, I’m assuming most of the folks joining us have had to be on blood thinners at some point as the premise of why we’re here. I don’t want to go overboard on the medical lingo but just want to orient us to the fact that there are sort of two different “flavors” of being on blood thinners: those who are on what we call a treatment dose or a full dose, and those who are on a prevention dose. Treatment doses are used to treat things like a recent blood clot, the original blood clot itself. Examples of that are pulmonary embolism, or PE, and deep vein thrombosis, or DVT. As I already mentioned in one of the vignettes, abnormal heart rhythms, particularly an abnormal heart rhythm called atrial fibrillation that can make clots form in the heart and then cause strokes as they break off and move around the body, is another indication to be on a treatment dose. And then mechanical heart valves which, since I’m a hematologist, I do not take care of those very often. But those are all reasons to be on a full or treatment dose. 

In contrast, and one of the things that’s really important to keep in mind when we think about some of the strategies we can use moving forward, is other reasons to be on blood thinners at a prevention dose, which is usually substantially lower, depending on which blood thinner, somewhere in the ballpark of half or even less than half the dose. And the idea here is that protection from blood clots, in some of these scenarios, might be accomplished with less than it takes to treat a blood clot that’s there. 

So with that, there are certain scenarios where we think about protection. It might be somebody who’s had a history of prior blood clots and they’ve done their treatment course, but now to prevent something in the future, we’re down to a lower dose. That might be continuously used or might just be used intermittently when there’s a specific extra risk happening for a brief period of time. Additionally, there are times where somebody might have a lot of extra risk factors for blood clots, especially a strong family history, and there are certain scenarios where we might use prevention for that purpose. And then there are other scenarios where we use prevention doses of blood thinners for everyone. 

As a great example, if you have knee or a hip replacement surgery, that’s really high risk for anyone, no matter their history of blood clots, and so you might be on a prevention dose in that context. And so not all this applies to everybody listening, but I think it’s important to realize that there’s two really different ways to be on blood thinners in terms of the intensity. When we think about the impact, though, for anybody who’s dealing with heavy periods on blood thinners, you are the norm. It’s not that you should deal with it, but approximately 70% of people getting their period, who are on a blood thinner, have officially heavy periods. And so that is, by far, the majority. 

You’re not in it alone, even if your doctor hasn’t stopped to talk to you about it, or even if you felt uncomfortable bringing it up. But the other thing to keep in mind in terms of the blood thinners is that not every blood thinner has the same rate of heavy periods. Specifically, as hematologists, we bucket these into two groups. It’s not that any of these blood thinners have no bleeding or no risk of extra bleeding, but there are ones that are have more and less. 

Both rivaroxaban and edoxaban have actually been shown to have meaningfully higher rates of period-related bleeding and heavy periods than other blood thinners. And so again, it’s not that these other blood thinners don’t also increase the rates, it’s just that enoxaparin, which is an injectable blood thinner, and apixaban, which is also called Eliquis^®, one of our most commonly used pills, have a lower rate of bleeding. So we can keep those in mind for comparison.

In terms of consequences of heavy periods, this audience probably doesn’t need me to spell these all out, but I still want to make sure everybody realizes that what you’re going through is not just unique to you. The number of different medical articles that show the high rates of missed school and missed work is so vast that I couldn’t cite them all if it was the only thing we wanted to talk about today. And I think those are common ideas: you can’t get through your work meeting, you’re doing an experiment in a lab, you’re trying to drive without having to stop to use a bathroom…

Another consequence—and I alluded to this in one of our opening vignettes—is avoided socialization. I have lots of patients who just feel more worried than able to enjoy themselves if they’re going to be in a scenario where they just don’t know whether they’re going to be able to control their period bleeding. And with that comes understandable anxiety about things like bathroom access and the embarrassment of bleeding through. I think there are a lot of cultural norms about how teenage girls in high school might have difficulty bleeding through; sort of one of these embarrassing coming-of-age stories. But that can add extra pressure and embarrassment when it’s happening to adult women, as though the answer was that you didn’t know what to do with your body or hadn’t gotten used to being a woman. 

If you’re having super heavy bleeding, this isn’t about you not having an understanding of what to do. It’s about the fact that the bleeding is really that heavy that it’s hard to navigate. And I know that that level of embarrassment or anxiety or difficulty just with the mess can be really limiting. These are all things that I think most people who are dealing with heavy periods don’t really need me to point out other than again to say that you’re in a safe space here, and we want to talk about all this and strategies that you can use to think about it and make it better. 

But the other thing that often gets neglected is that losing all this blood means losing iron. Every time red blood cells leave your body, they take iron with it. And so, having heavy periods is the single most common way become iron deficient. So with that, whether or not you’re also anemic is another big consequence of heavy periods that gets under-addressed and can be adding to your symptom burden and reducing your quality of life. 

What’s important about iron deficiency is that we always think about it in two buckets of symptoms. We have symptoms related to anemia, when your iron is so low that you can’t make enough red blood cells. But there are also some symptoms I’ll come back to in a moment that really are about the iron itself, even if you’re not anemic. So common symptoms of anemia—whether it’s from iron or otherwise—

include fatigue, shortness of breath, and decreased exercise tolerance. That last one is our medical term, but you can think about it as the idea if you’re a runner, maybe you can’t run as many miles. But it can also manifest in other ways in your life, like, you used to have no problem walking eight blocks, carrying your groceries back to your home and now that’s just not doable – and you’re having a hard time with those routines of daily living in a way that’s really limiting. 

We also want to think about some of the symptoms of iron deficiency that aren’t just from anemia, because sometimes doctors do a bad job about catching the iron deficiency if people haven’t gotten all the way to being anemic, but that’s actually a late manifestation of iron deficiency. And brushing off symptoms from iron deficiency, just because someone isn’t anemic, is not appropriate. So, with nonanemic iron deficiency, meaning your red blood cell number is still normal—we usually measure that through hemoglobin—but you have low iron, you can have fatigue. (separate from the anemia) and other symptoms that can be really troubling like hair loss, restless leg syndrome, which can keep people from sleeping well at night, further adding to how exhausted you feel. 

A very common symptom of iron deficiency is a craving to chew on ice or clay. And then doesn’t apply to anyone where I’m living because I’m in Massachusetts, but people are more prone to altitude sickness when iron is there. So just a few different reasons to be careful about this. 

With that, there is some lab monitoring when you’re on blood thinners that’s important for everyone –

and then we’ll talk about some things that are not true for every single person on blood thinners but really important for everyone here today to keep in mind. It’s typical with any blood thinner—if you’re on one—to be getting your blood counts checked every 6 to 12 months. With this, we’re looking for anemia. I think I just heavy handedly explained why we’re worried about that. Then checking your platelet count, another part of your blood that’s important for forming blood clots and making sure you’re not at extra risk of bleeding as a complication. Since some blood thinners are cleared out of the body by the kidney, we want to keep an eye on kidney function, too. All that’s an expectation of part of your care. 

With heavy periods, though, something that often gets neglected—and part of why I want everyone here to feel empowered to advocate for themselves—is directly checking that iron. I won’t torture everyone with the details of how hematologists keep track of iron, but it’s really important, actually, to learn the name of this other test, ferritin, because that’s actually the warehouse for your body to keep iron and it’s more accurate than the iron number itself. These are things that, if you have heavy periods, should be checked. Every single time you’re getting blood counts might be excessive, but a couple of times a year, ferritin should be checked on if you’re continuing to have heavy periods. And sometimes it needs to be more frequent than that if it’s been a recurrent issue for you.

I won’t go too far into it today, but for those people who are on warfarin as their blood thinner, INR, or international normalized ratio, tests are also important; that’s how that blood thinner is managed. And for folks who are on it, they’re probably very familiar with this, so I won’t belabor that. 

So, I’ve gone through a lot of background and a lot of things. But up until now, I’m sort of telling people some things you may already know, and we want to shift over to what you can do to help manage your periods. 

The first thing, and part of why we started with this idea that not all blood thinners are the same, including how much of a dose you’re on as well as the type, is that switching or adjusting may be an option. You may be able to adjust your blood thinners if it’s safe. You may have a condition or scenario in which it’s not appropriate to use one of these strategies. But a lot of the time, the first step can be switching to one medication with less bleeding. So, for example, switching from rivaroxaban to apixaban. Another example might be if you’re a person for whom it is safe and appropriate, dropping the dose level to prevention dosing instead of the full dosing because this is something that we know has a lower rate of bleeding. Alternatively, if you’re a person for whom it’s safe, one strategy I use a lot is to hold or reduce the dose just temporarily around the heaviest days of the period so that peak bleeding isn’t occurring with blood thinner in your system. I want to be really careful to say this doesn’t apply to everybody. But all three of these strategies—and sometimes in combination—can make a huge difference if you’re the right person. So just checking in with the person who does know your medical history, your hematologist or cardiologist, may be able to determine if one or more of these things might help you deal with your heavy period.

Additionally, in terms of contraception, I will pause and say that the term “contraception” in this context is always a little bit frustrating. We don’t have a medical term for all the things that we use to reduce periods that act by also preventing pregnancy. So, we’re talking about contraception here, but most of the time, the motivation is not to block pregnancy but to control the periods. We’re going to go over, in a few moments, contraception choices that have different clotting risks, and there are some that don’t have any clotting risk that could be really helpful for your care if you’re not already using it. Additionally, we want to address the iron deficiency. It’s a side effect of being on blood thinners, but it’s not a side effect you have to live with. We have really effective treatments. There are both pills and IV formulations of iron that are available in most places. And you should be able to get to it if you have persistent iron deficiency and can’t tolerate pills or they’re not working. I’ll come back to that in a moment.

Additionally, I hope part of this helps in finding the right emotional support, because whether it’s because we can’t get all the way there in terms of medical conditions really requiring you to stay on blood thinners or having that only partially controlled periods or just being exhausted from all the medical visits you have to go do to get this sorted, I really hope that you understand that this is hard. And just because as a society, we don’t want to talk a lot about periods doesn’t mean that you should have to feel alone in coping with it. So, I hope this is one of many things that you can use to find just that good emotional support to get through dealing with this.

I mentioned that contraception and clot risk is not the same across all different types of contraception. I’ll mention here there are two buckets of contraception that don’t have extra clot risk. A copper intrauterine device, or IUD – which for this discussion, I should flag that it’s specifically known to actually increase bleeding while being extremely effective at preventing pregnancy. So, while it’s absolutely true that it doesn’t have an extra clot risk—and it’s totally fine if you want to use it in terms of preventing pregnancies—it is not going to help you if your motivation is to reduce heavy periods; it’s actually going to do the opposite. Part of the reason why I have it here is also to mention that if you yourself have a copper IUD and have heavy periods, switching to a different type of IUD is one of the things that you can consider as an intervention because sometimes people don’t realize that there are other options that are safe, even if you have an extra risk of clotting or have had a clot yourself.

Most progesterone-based methods—and I’ll explain what those are because I know not everybody’s going to know what that means—are safe. Specifically, the other type of IUD, this thing that gets inserted into the uterus to prevent pregnancies, is safe. We know that from lots and lots of data. Levonorgestrel is the generic name, but most people will know these IUDs by their brand names, which are Mirena^® and Kyleena^®; these are the main ones in the US and an be placed in the uterus in an outpatient setting with very low risk. Experienced gynecologists can place it without stopping blood thinners. They can last for years. 

Progesterone-only pills are an alternative that are also very, very effective when used correctly. But, of course, you have to take a daily pill, which if you already have a large pill burden, maybe that’s not something appealing to you. 

And then there’s the etonogestrel implant – and I will tell you medically almost no one calls it that because it’s a bit of a tongue twister, but people familiar with it will know it as the Nexplanon^® implant that goes in your arm. So, those are all different forms of contraception that are clearly shown to reduce periods. Some of them even stop periods altogether and are completely and totally safe to use with a prior clotting risk.

On the other hand, things to avoid and things to be careful about include estrogen-containing contraception. So, this is the classic pill, the standard thing that most people are aware of. This one definitely increases the risk of blood clots in all the different formulations, including the low-estrogen ones; and if you have a history of blood clots, it’s usually not appropriate to use these. Having said that, people with special scenarios who really, really need to be on an estrogen-containing medication can talk to their doctors about how to find ways to minimize that risk and stay safe.

The other thing I want to point out—and I put special emphasis on this because this is an area I know a lot of other doctors are actually unfamiliar with—is that there’s one form of progesterone birth control that is clearly associated with a higher risk of blood clots, and that’s the shot, the Depo-Provera^® shot, as the brand name of progesterone. We don’t 100% understand why that’s the case but it’s been clearly shown across studies, and I think it probably is just because it’s so much higher than the amount of progesterone that’s normally in the body. In a lot of other scenarios, this is an excellent form of contraception or control of periods. But if you have a personal history of blood clots, this is an important thing to be aware of. Again, because this is often not something a lot of doctors and other healthcare providers are aware of, they sometimes mistakenly lump it with the other forms of progesterone-based birth control. So, that is a hematologist’s take on contraception.

In terms of things to share with your doctor, before they can give you good advice, they have to know things. And I really wish that every doctor taking care of someone on blood thinners would just ask all these questions and not have patients have to offer them. I just know that’s not the case, and sometimes that’s because people just don’t feel comfortable. We should. But with that, here are things you really want to let your doctor know about: tell them about your periods! Hopefully they’ll bring it up, but if they don’t, you should. 

Tell them if your cycles are regular or not. That helps us with things like the idea of  “I can’t ask someone to reduce their dose for the first few days of their period if I have no idea when that’s coming.” So, cycle information might help us think a lot about what different approaches we can take,  and then help them answer those questions that I said define heavy menstrual bleeding. Tell them the number of days you bleed for; how frequently you have to change a pad, tampon, or whatever you’re using; and if you’re passing clots bigger than a quarter. Also share with your doctor how this affects you. This is not necessarily something you’re going to be able to talk about on end just because we know doctor’s visits can be really crammed. But let them know if you’re having symptoms that you think might be related to iron deficiency to help them remember to check. 

If you’ve been started on iron pills, let your clinician know if you aren’t able to take them. These are really helpful for dealing with iron deficiency, but they’re notorious for causing nausea, acid reflux, and constipation, so lots of people can’t take them. And you should just share that with your doctor. With iron pills, nobody’s going to be especially surprised that you’re not able to deal with them, and that’s a great time to pause and think about other ways to get iron into your body. 

Tell your doctor about pregnancy or contraceptive needs as well. I just went through a whole long list of the different contraceptives and how some of them might help. If you’re trying to get pregnant, it’s obviously pretty darn tone deaf for me to tell a patient to get an IUD, as that’s meant to prevent pregnancy for several years. And if you aren’t sexually active, that might change what you want to do. Or if you’re, you know, worried about getting pregnant, there might be an urgency. So just do your best to share those things. 

I want to pause and point out that doctors are not all the same in terms of what they’re expected to deal with. So, I think most of you have met a hematologist or cardiologist that’s managing your blood thinner, and again, they’re things to ask them about. Are you a person who might be appropriate to drop down to a prevention instead of a treatment dose? Is it appropriate for you to—in the context of your own medical care—be on less intense blood thinners during periods? Or could you switch between the different blood thinners to one that has a slightly lower rate of bleeding to see if that’s really impactful for you? 

Also, ask them directly if they’ve checked for iron deficiency. Maybe they’ve been so focused on your blood clot that they forgot to step back. And if it’s done politely, I never take offense to my patients bringing up something that I wanted to get to later in the visit or at another visit if it’s important. You can also ask them if you’re having difficulty with iron pills, or very, very anemic if you might be able to get iron by IV. I know not everybody’s coming from large medical centers or might be in different circumstances, but this is something we do routinely for many of our patients at the Brigham and Dana-Farber, and so this is accessible to a lot of folks.

There are also some questions that I would say while your hematologist/cardiologist might have an opinion, they’re going to need to pull in a collaborator. Specifically, while I clearly spent a lot of time thinking about different contraception, I don’t place IUDs and neither do the cardiologists. So if an IUD or a progesterone implant is something you’re interested in, you’re going to need to have a primary care or gynecology team that is able to offer that to you. They usually are the ones writing prescriptions for other forms of contraception as well.

The other thing to keep in mind is if your periods were heavy, even before blood thinners started, make sure someone steps back and thinks about why. If they’ve been heavy lifelong, maybe that’s just the bad luck of your genetics, maybe there’s time to pause and think about other reasons to be prone to bleeding. But oftentimes, if periods have been escalating, especially as you are aging, there might be things the gynecologist needs to look for, like endometriosis or fibroids. 

Perimenopause is one of those other topics that we don’t talk about very much as a society. And I think if you watched a movie or something as your only way of learning about it, you’d probably think that people just gracefully have their periods peter out and stop bleeding. But in reality, it’s extremely common for periods to get heavier approaching menopause. The cycles become more irregular, and hormones fluctuate more. And so there are different strategies that we can think about depending on the cause, especially if there is something like a fibroid, which is something in the uterus can…like air in the uterus can bleed more readily, that there are other approaches other than thinking about it just from the hematology perspective. And so, I just want to make sure that people don’t anchor so much on blaming the blood thinner that they forget to step back and think about other things that might be adding to the bleeding.

There are also some things that you absolutely should not do without talking to your doctor. Even if you think you fit the person I described who might be a candidate to stop or decrease or pause your blood thinner, talk to your doctor about it beforehand, so we don’t have something scary happen. Some people, for a variety of reasons, are asked to take aspirin alongside a blood thinner, and sometimes that’s medically necessary, but it’s associated with more bleeding risk. NSAIDs are the group of medications that include Advil^®, Motrin^®, and Aleve^® (generic is ibuprofen or naproxen). So that’s another class of medications that carries some bleeding risk. 

The last consideration is starting supplements. It’s not that I have an issue with vitamins or over-the-counter supplements in general, but there are some supplements that have interactions with blood thinners. For example, turmeric is really popular right now, and there are certainly some benefits to being on it. But it also interacts directly with some of our blood thinners and, as a result, can meaningfully increase bleeding risk. So if you’re thinking about starting a supplement, it’s not that you can’t necessarily – but I would imagine that there are many people listening who had no idea that the levels of turmeric that are used in supplements (not usually in cuisine) might interfere with their blood thinners. So it’s important to just keep those things in mind.

I know that I just dumped a lot of information on everybody. As a person who does a lot of education, both with patients and with our medical students, I know that this is a lot to absorb at once. But just keep in mind that if you need to hear things more than once or want to get into more depth, there’s a lot of different resources availabl!