Hello all I hope your monday is going well!
This past weekend I got asked a couple questions by one of my new followers. She has yet to be diagnosed with endometriosis but is suspicious she could have it. She experiences a lot of pain during menstruation and also suffers from pain in her lower back. However she does not bleed a lot and was wondering if it was possible to have endometriosis without heavy periods.
I have encountered this question a few times and would like to take a moment to address it. First of all we must understand the physiology of endometriosis. Endometriosis is classified as a condition where endometrial like cells, similar to the ones that line the inside of our uterus, grow elsewhere in the body. Endometriosis is not considered to be a disordered that affects the normal endometrial lining of the uterus. Most often endometriosis appears some place in the abdominal cavity. In such cases the blood from these lesions pool in the bottom of the abdominal cavity until reabsorbed. My point being that blood from endometriosis does not always travel out the vagina as normal menstrual blood does and therefore may not increase the visible blood loss. So the answer is yes, it is possible to have endometriosis without heavy bleeding.
So now that I have addressed that question I would like to speak a little bit more on the topic of heavy bleeding. When an abnormally high amount of blood is lost during menstruation it is called menorrhagia. Menorrhagia can be caused by multiple physiologic conditions from pelvic disorders that affect the uterine lining like adenomyosis and fibroids to systemic blood clotting disorders (coagulopathies).
Menorrhagia can be a hard syndrom to diagnose because women don’t have an easy way of knowing how much blood loss is normal. On average there is about 35-40 ml of blood loss during menstruation. 60 and 80 ml/month is the upper end of normal over 80mls is considered dangerous. So how on earth do we know how many mls we bleed? With the rising popularity of menstrual cups measuring blood loss is a bit easier. When a cup of a known volume is used a patient can record how many times a day the cup was change and how full it was each time. This method creates a rough estimate of blood loss volume. If you are worried that you may have menorrhagia I suggest trying this method for a couple of cycles and recording your blood loss. This will allow your Dr. to understand a quantitative value. If you are unfamiliar with or can not use cups you can also test how many mls liquid your brand of pad or tampon holds. Then count how many you use per month. This method will still give your gynecologist important information. Here is a good chart to use to record flow before your next Dr. appt.
Menorrhagia can pose multiple problems. Most obviously heavy bleeding can affect daily activities. Women with menorrhagia often have to make trips to the bathroom every hour to change sanitary products. Secondly, enough blood loss can cause iron deficiency (anemia). Without iron your body can not produce hemoglobin, without hemoglobin your blood loses its ability to circulate oxygen around the body. Without proper blood oxygenation patients can experience a multitude of symptoms including headaches, weakness, fatigue, nausea, and in severe cases shock and death. It is extremely important that women experiencing excess blood loss take supplemental iron. If you experience any of these symptoms during menstruation it is important you bring them up with your gynecologist.
Earlier I explained that you can have endometriosis without menorrhagia but now I would like to explain why they two are so often lumped together. The most recent study I could find stated about 70% of women with endometriosis experienced menorrhagia. However this study was done using patient history and there was no quantitative values on how much blood loss was considered henorrhagia. It is likely that some women losing less than 80 ml of blood per month believed they were experiencing menorrhagia. Also the study was performed in the 80s. It is likely only women with more extreme symptoms took part in the study because many physicians did not, and still don’t realize the multiple faces endometriosis can have. This study may not realistically reflect all endometriosis cases including underdiagnosed presentations such as women with endometriosis who do not experience pain, heavy menstruation, etc. That being said, a few arguments can be made reasoning that the physiology behind endometriosis could predispose endo warriors to other estrogen mediated syndromes like adenomyosis and fibroids. Related reproductive syndromes could explain the elevation of menorrhagia diagnosis women with endometriosis.
So in summary not everyone with endometriosis experiences menorrhagia, but women with endometriosis may have a higher likelihood of heavy menstruation secondary to other reproductive disorders. Lack of heavy menstruation should not dissuade women suffering with pain from pursuing a diagnosis. Also women who believe they could be experiencing menorrhagia should record blood loss and report to their doctor to insure they are not at risk of experiencing iron deficiency, bleeding disorders etc.