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Growing Stronger Together is a podcast for people who care about children.
Growing Stronger Together was developed by faculty at East Tennessee State University, including members of the ETSU Health Department of Pediatrics, the ETSU Center for Early Childhood Learning and Development, and the ETSU Child and Family Health Institute.
East Tennessee State University is located in the beautiful Appalachian Highlands. We appreciate the financial support provided through a Community Health Improvement Site Investment from Ballad Health’s Department of Population Health.
Dr. William Dodd (00:00:02)
I'm your host, Dr. William Dodd, ⁓ from the East Tennessee State University Health Pediatrics Adolescent Medicine Clinic.
This podcast is not intended to provide medical advice. ⁓ If you or a loved one are working through medical problems related to today's topic, please consult a personal physician. ⁓ I have no conflicts of interest to disclose. ⁓
Today we will talk about period problems and how to prevent them.
Dr. William Dodd (00:01)
I'd like to welcome everybody to another episode of Growing Stronger Together. today
Is my great pleasure to introduce our guest, Dr. Quinn Owen. Dr. Owen is originally from Potomac, Maryland, and went to the Virginia Tech Corellian School of Medicine for medical school and joined us here at ETSU for residency in pediatrics. she's interested in pursuing a career in hematology oncology, though everything is still in the works as it usually is during residency. Dr. Owen is an
avid hiker. She enjoys hiking with her husband and dog and she is also a fan of coffee and I think we can all agree on that. So welcome to the show, Dr. Owen.
Dr. Quinn Owen (00:49)
Yeah, thank you so much for having me. To be here.
Dr. William Dodd (00:52)
So today we're gonna talk about a kind of a interesting topic, an important topic that sometimes is not talked about a lot. And so Doctor Owen, why why don't we talk about some terminology first?
Dr. Quinn Owen (01:09)
Yeah, of course. So there can be a lot of terms in this area that are confusing. So I just wanted to kinda lay some groundwork here. the average menstrual cycle, the first one is the length of your period, f fully the bleeding and non-bleeding phases. lasts about twenty-nine days, but that can range from twenty three to thirty-nine days. And the bleeding itself lasts between two and seven days.
Abnormal butyrine bleeding is just any deviation from that normal menstrual cycle that we just described. heavy menstrual bleeding, which is what we'll be mostly talking about today, technically is defined as greater than eighty milliliters of menstrual blood loss per cycle. But as you might imagine, that's pretty hard to quantify. So other definitions are used that kind of
basically try to take into account more of something that interferes with the patient's quality of life, either physically, mentally, emotionally, things like that.
Dr. William Dodd (02:09)
So that takes it from more of a scientific definition to a practical
Dr. Quinn Owen (02:13)
definition.
Yes, yeah, of course. Yep. and then prolonged menstrual bleeding is bleeding that lasts longer than eight days. So now we're talking about duration more so than volume. Again, both of these are kind of often used interchangeably. this can this one can happen, but it's not necessarily associated with heavy menstrual bleeding. But the major point probably with those two is is it interfering with the patient's quality of life? Because that's what we
can more appropriately measure when talking to to our patients.
Dr. William Dodd (02:48)
But what about maybe some are there any other related terms that you might hear?
Dr. Quinn Owen (02:54)
Yeah, so there are other terms that are used a lot in the scientific community that are falling a little bit more out of favor now. that would be menoragia or metorasia. as you can guess see here, those those sound pretty similar, so it can be confusing. But menorage is generally abnormal uterine b bleeding. Meterasia is increased duration of the menstrual flow. so we like to stick to terms that are a little bit
more intuitive like heavy menstrual bleeding, abnormal uterine bleeding or prolonged menstrual bleeding.
Dr. William Dodd (03:29)
Thank goodness. I mean as a doctor I feel like I've got to use fancy words, otherwise why are people paying me? But I always hate saying metro minoraja. I feel like there's a more effective way to communicate the problem.
Dr. Quinn Owen (03:42)
Yes.
Yes. Far too confusing and sound way too similar. and for the most part we're gonna be talking about bleeding within the bleeding episode of the menstrual cycle rather than intermenstrual bleeding, which would be bleeding that occurs outside of the regular menstrual cycle.
Dr. William Dodd (04:08)
All right, and what about does this fit into any sort of larger framework at all?
Dr. Quinn Owen (04:14)
Yeah, so yeah, so abnormal uterine bleeding, like I mentioned earlier, is is a much larger category. It can be a variety of structural and non structural causes that can contribute to that, which we'll get into a little bit later. but we are trying to stick to just cases of heavy menstrual bleeding, which like I mentioned is just the bleeding
within the menstrual cycle rather than outside of the menstrual cycle or of other etiology or causes.
Dr. William Dodd (04:46)
Well and you know, as the listeners to this podcast might know, I'm very active in the in the community and our program is very active in the community and one of those outreaches that we do is we work with schools, high schools, and we have a reproductive physiology discussion that we give and one of the topics on that discussion is you know, normal period, abnormal period.
What's the difference? And it seems like after every single lecture session that we give, somebody'll come up to me and say, Hey, you know, you know, I heard about your talk on the period and realize there might be something going on and I need to see my doctor and and so I feel like it's relatively common. Do you have any data on how common y abnormal uterine bleeding is?
Dr. Quinn Owen (05:44)
Yeah, absolutely. So there's a variety of reports out there, but one that I found the annual prevalence rate says about fifty-three per one thousand women. but a much higher percentage actually present with the complaint of abnormal uterine bleeding per year, about twenty to thirty percent of women presenting to their care provider. so there are major impacts to the quality of life, productivity and the health care costs.
around this this field and it's really important to recognize when it's affecting the quality of life of somebody outside of even that scientific definition that we mentioned earlier.
Dr. William Dodd (06:28)
Yeah, abnormal uterine bleeding or you know painful bleeding or or heavy bleeding are the most common reason for young women to miss work or school or you know, anything that they need to do. So it's a really important topic. if you're talking to a patient, how would you establish a history of abnormal bleeding?
Dr. Quinn Owen (06:51)
Yeah, so it can be kind of hard. Often, asking a patient, how's your period? They might say normal. just like another possibly taboo topic, your bowel movements or your poop, what someone might think is normal, really is quite different for each person. you're the only one experiencing it and so it's it can be hard if you're not talking about it with a lot of people to
to recognize kind of some of the more subtle differences there. So major key points that I like to ask patients about,
would be the total number of bleeding days from start to finish, the number of pads or tampons or alternate sort of collection device that they are using, or if not, how many pairs of underwear they're going through or pants a day, and how frequently they're changing those during the day. The other thing that can be kind of missed during the interview on that part is throughout the night too. Some patients
might be getting up at night, other patients might not be, and so recognizing what's happening at night too is an important thing to ask about. and then finally asking about blood clots and specifically what size. A common sort of threshold that we use in medicine to help distinguish the size of clots is the size of a quarter. And so
kinda whether that's a clot you see in in the underwear or in the in the toilet, those are some things that can help kind of start out the history of how heavy this this bleeding is. but that's not all. We ha we don't want to interpret any abnormal bleeding without having the full history of the patient, you know, knowing their full his medical history is really important. so we
typically like to get a gynecologic history, an obstetric history, as well as just general medical history. so some of the gynecologic history that we talked about is when when was menarchy or the first period, how long ago or how new are these periods? because sometimes the if it's a a newer it can be irregular and that can be normal, but knowing the how long the patient's had their period can be helpful.
And then since they started, like I mentioned, have they been getting them regularly? Do they ever skip months? another question would be have they ever been pregnant before? Is there a chance that they could be pregnant currently? because there can be some spotting or bleeding during pregnancy that might lead you astray in terms of your thoughts on answering that question. another thing to think about is any other discharge that they're having vaginally.
and being specific. This is another one of those tabby topics that patients often maybe aren't talking about as much, and so it's hard to know what's quote unquote normal. so asking about discharge, you know, texture, odor, frequency, quantity, those can help kind of distinguish more of the benign discharge from any kind of underlying infection or other etiology. and then
Finally with the bleeding history, just being certain that the blood is actually coming from the vagina versus another place, which can sound like a silly question at first, but it's not always easy to tell when there's a toilet bowl full of blood, which can be a very jarring and confusing finding. So s for instance, is it actually coming from your rectum, your bottom, and you might have a hemorrhoid or a fissure that's having some bleeding, or
Is it actually in your P and coming from urethra where your urine comes out as hematuria, which might lead you to a different question. So lots of history from the sort of gynecologic and obstetric portion that are important to to parse out there.
Dr. William Dodd (10:51)
Yeah, and and I think you're absolutely on point to to recognize how difficult it is for patients to talk about these things. I think a lot of times as older adults, for lack of a better word, we kind of forget what it's like to be a teenager, but but you know, these are people who have never had like pap smears, so they're not used to talking about reproductive health. You know, they're
We're kind of conditioned not to talk about these sorts of topics as a society and it can really be hard for people even to have a conversation with their doctor about a lot of these things.
Dr. Quinn Owen (11:32)
Mm-hmm, yeah, certainly.
Dr. William Dodd (11:37)
are there any other historical tidbits you wanna glean from your a discussion or
Dr. Quinn Owen (11:44)
Yeah, yeah, definitely. So, like I mentioned, not just the kind of specific history, but the overall picture of the patient and their sort of health journey are important. So any other medical diagnoses that they have, such as diabetes or bleeding disorder, those can be some prominent ones that can affect your menstrual flow or or thyroid problems. are they taking any medications or any even supplements or herbal remedies, things that maybe are not prescribed but you can buy over the counter are important.
to ask about too, because a large number of any of those things can affect your ability to to stop bleeding and or to continue bleeding and might affect the length of the length of the period. any other surgeries or recent procedures? just broadly speaking important especially any surgeries are kind of in the abdominal area
or in the pelvic area might lead you to more structural concern or acute concern. and then even small procedures such as a pap smear or something else that might that might cause a little bit of bleeding afterwards that the patient might be not be so acquainted with.
and then a family history of bleeding disorders is also porton important to ask about too. the patient might not know that they have a bleeding disorder, but it could be something that could be contributing to the heavy menstrual bleeding. so if it's something that runs in the family, a lot of these are genetic, knowing that piece of history would be important.
And then trying to parse that out a little bit more, any bleeding history of the patient specifically. So have they noticed bleeding anywhere else, like prolonged nosebleeds or gum bleeding when brushing their teeth, or any blood and any other secretions around the body, like coughing up blood, any blood in the fumat, urine or these signs of some
bleeding problems in other areas. and then any easy bruising or rash of some peculiar red purple spots that we like to call patiae can be indicative of some underlying clotting problems as well. And then finally a more kind of subtle one might be joint smelling in family members. That's usually in males, but females can have some some sequela of that disorder too.
Dr. William Dodd (14:10)
Yeah, and you know, it seems like a lot of times you'll kind of uncover a history of free bleeders or lots of hysterectomies in a family and kinda uncover some of that. And that's a really good point about supplements too. I I don't think a lot of folks
consider when looking at supplements that a lot of those affect hormone systems, which can then affect you know, periods. They can also affect bleeding tendencies like St. John's wort, which is commonly used for depression, very effective anticoagulant, so so a lot of these seemingly safe supplements are actually can be the root of a problem.
Dr. Quinn Owen (14:56)
Yeah,
yeah, certainly.
Dr. William Dodd (14:58)
But so we got all this history and what do you look at from that history to make a diagnosis of heavy menstrual bleeding?
Dr. Quinn Owen (15:09)
Yeah,
the American College of Obstetricians and Gynecologists, or commonly known as ACOG, is a a very well known sort of governing body of the OBGYN world, and they have put out some guidelines on their website which is very helpful. they say that bleeding that lasts more than seven days is concerning, something we should looked into. Bleeding that soaks through one or more tampon or pad every hour for several hours in a row.
needing to wear more than one pad at a time to control menstrual flow, needing to change pads or tampons during the night, and then menstrual flow with blood cods that are as big as a quarter or larger are all important things to be thinking about that should be raising your flag, red flags for you in terms of heavy menstrual bleeding.
Dr. William Dodd (16:01)
And pretty straightforward too. You got bleeding longer than a week, bleeding more than changing a pad every hour, and then clots a quarter or bigger. those are all pretty pretty easy thresholds.
Dr. Quinn Owen (16:17)
So Yeah, yeah, it's a good way to to still it down and make it something more easy to remember from the patient side of things. Especially if you sorry to cut you off there. Especially comparing it to often how often are you going to the bathroom a day just to urinate, is a is a good way to kind of get at the frequency of changing pads or tampons that can make it sort of a more approachable question for for patients.
Dr. William Dodd (16:42)
I mean, what about once you uncover some of this history though, what on earth causes heavy menstrual bleeding?
Dr. Quinn Owen (16:49)
Yeah, so there are a large, large number of causes. there are structural causes such as fibroids or polyps, which are essentially either larger pieces of tissue connected by a thin stalk in the uterus or endometrial or structural differences in the
in the uterus that can cause more endometrial lining. obesity can cause high estrogen from the excess adipose tissue and that can cause endometrial hyperplasia, which is just
Excess growth of that menstrual tissue or polycystic ovarian syndrome, which can is well known to have irregular periods. And then other causes like we've kind of touched on already, such as bleeding disorders. It's important to know that not every patient with heavy menstrual bleeding needs to investigate for an underlying bleeding disorder. And usually some of those other signs and symptoms that we talked about earlier are present too. But typically the general
pediatrician or a pediatric hematologist will get that history and then do further testing.
as needed. But it is reported that about thirteen percent of women with abnormal butyrine bleeding can have some sort of variant of Wan von Willebrand disease, which is the most common bleeding disorder, and then twenty percent can have any type of underlying coagulopathy. So bleeding disorders are always something high on our list that we're thinking about when we're talking to these patients. And then other things we kinda touched on this earlier as well, but medications,
or certain birth controls, such as the copper IUD, might actually cause more bleeding than than typical. but that's a lot of things. It's really hard to remember. So there is a a lovely acronym that several of the governing bodies in the OBGI GYN world have come up with called Palm Palm Cohen. It's P-A-L-M-C-O-E-I-N. and that stands for polyps.
adenomyosis, which is just endometrial tissue in the uterine wall, leomioma, any malignancy, coagulopathy, ovulatory dysfunction, endometrial tissue, iatrogenic causes, such as the IUDs like we talked about, and then other not yet classified disorders.
Dr. William Dodd (19:21)
Well fair enough. I like acronyms that spell a word though.
Dr. Quinn Owen (19:27)
Yeah yeah.
Yeah. That I guess that one is I don't know, it's i that one is stuck in my head from medical school but without studying it pretty hard that is a that is a difficult one to remember. I think the L was added. I used to remember Pam Cohen and it sounded like s somebody's name and that's how I remembered it. And then just stuck the L in there.
Dr. William Dodd (19:45)
That it that is from the
Well, they should move it elsewhere.
Dr. Quinn Owen (19:51)
Yeah.
Maybe the middle initial.
Dr. William Dodd (19:54)
Well, what what co what kind of symptoms might a patient have if they're having heavy menstrual bleeding?
Dr. Quinn Owen (20:04)
Yeah, so if we talk about some of the complications of heavy menstrual bleeding, that'll help us get at the symptoms. But with blood loss, one of the things that we worry about is anemia. Either you acute blood loss anemia, which is anemia from losing blood all at once is the term I infer, or iron deficiency anemia, which is more of kind of a chronic nutritional deficiency that you develop from losing so much blood over a long period of time.
but the range of symptoms from that can vary pretty wide widely. in the more chronic setting, some patients' bodies may have adjusted to it, so they might be asymptomatic and not not realize that they're having some anemia. Other patients might be feeling some dizziness, lightheadedness, some fatigue, some heart racms, and even some shortness of breath sometimes.
Dr. William Dodd (21:00)
So there's pretty wide variety, I guess.
Dr. Quinn Owen (21:03)
Yeah, yeah, it can range from a lot of things and and active teenagers sometimes it it is it's hard to tell what is w f fatigue just from having to get up so early for high school versus fatigue that might be caused from from low blood counts. So important to kinda power set all this stuff.
Dr. William Dodd (21:22)
And you know, w one other symptom I I see a lot of times in teenagers, which is just it blows my mind every time I see it is pico where th they'll eat you know, eat something the body just has a drive to eat something gritty, because that's where iron exists in our environment, naturally. So people eat all sorts of wild things though. They'll eat flour or cornmeal or pancake mix.
And just, you know, you kinda talk to somebody, you're like, Why you know how how is this something that you wouldn't come to me sooner about?
Dr. Quinn Owen (22:04)
Yeah,
yeah. Yeah. The body has some unique ways of raising flags to us, I think, and that's definitely one of
Dr. William Dodd (22:13)
Well w what kind of lab work would you get, whenever you see a patient like this?
Dr. Quinn Owen (22:18)
Yeah, so one of the most common things that we think about is just checking a complete blood counter. That's typically your blood level. So your hemoglobin and your platelets. Your hemoglobin is what carries the oxygen and can if it's low can cause a lot of the symptoms we talked about. and then your platelets are involved in stopping bleeding in your body. So if those are really low, that might be another source. we also look at the size of the red blood cells. That can help us differentiate between different types of
anemia, whether they're big, small, or normal, versus their color might just be pale looking. and then other labs you wanna look at typically are liver function tests that
the liver makes a lot of the factors in your body that help with clotting and stopping bleeding. So if there's an underlying liver problem, then then that might present itself downstream as some problems with clotting. And then thyroid studies too, because thyroid abnormalities, both high and low, can can cause abnormal bleeding. and then depending on that history we got earlier, if a bleeding disorder is suspected, then testing for von Willebrand disease or other
coagulopathy labs might be sent as well. If the concern is more structural, then some imaging like an ultrasound might be done as well.
Dr. William Dodd (23:41)
So a pretty extensive workup, but a lot of times you might uncover something.
Dr. Quinn Owen (23:47)
Yeah, certainly, certainly. And your your history can often lead you in the direction of of what to work up, but sometimes it's important to check check a variety of things just to make sure we're not missing something.
Dr. William Dodd (24:01)
Sure, and and sometimes you do see like life threateningly low hemoglobins from abnormal uterine bleeding. Well and let's say you get the diagnosis, what do you do about it?
Dr. Quinn Owen (24:11)
Yes, certainly.
Yeah, so like you mentioned it c we can have l life threatening levels of anemia or low hemoglobin or less so. so typically when thinking about this I like to differentiate the patients in terms of how they're presenting and what we've found. So someone who's having no symptoms, with a low to b more normal in the normal range of a hemoglobin
Typically we're not doing anything urgently like running to the hospital or starting active pharmacologic interventions, but affecting their quality of life may still want to regulate their cycle. So we can use some hormones to help limit and regulate the bleeding, which we'll talk about those in in a minute. the other extreme would be like you mentioned the patients who are completely symptomatic and even hemodynamically unstable.
which is sort of our fancy word for saying their vital signs like their heart rate and their blood pressure, maybe indicating that they've had quite a bit of volume loss and that might be causing risks to other organs in their body that need the oxygen that that blood is carrying. so often immediate intervention is required in those settings that would be more in the hospital setting, and can include things like blood products, other IV medications to stop the bleeding, things like that. And then
ultimately a plan for regulating the period will be put in place. and that brings us to what a large portion of patients have, which is a category of symptomatic or even life-threatening low hemoglobin without symptoms because their body or symptoms that they're aware of because their body has sort of adapted to it, but without that life-threatening hemodynamic instability or vital sign changes. So
These patients typically benefit from regulating the period to prevent heavy bleeding. how we regulate the period is usually with different hormonal methods. we can also call this birth control, because that's another use for some of these medicines, but they can be used to regulate the period even in patients who are not sexually active. so these
Different hormonal options range. We can have daily pills to other implantable methods, but usually for the purpose of regulating periods, the daily pill or otherwise known as OCP or the oral contraceptive pill is used. the patient really it's the decision of what to do is really should be a conversation between the provider and the patient. But in brief the hormones we use are
estrogen and sometimes additionally progesterone and those are naturally occurring hormones in the body. So we're not introducing something new, just just kind of helping the body to regulate this process that it's already doing. and they help to regulate, yeah.
Dr. William Dodd (27:23)
and and and you're right, it's it can be a touchy sub subject sometimes and sometimes parents are just very resistant to their kids being on hormone medicine, you know, even if they're bleeding to the point that is threatening their health, sometimes it's just a very difficult conversation to have and there are a lot of th a lot of
kind of cultural considerations that go into that decision for for parents a lot of times that, you know, are even maybe more d detached from the medical realities of the situation that we gotta do something about this, otherwise it's gonna cause harm to the kid.
Dr. Quinn Owen (28:08)
Yeah, certainly. When you hear the word hormones and adding things it can be kind of scary, you're thinking that we're doing something outside of the body's normal processes. but really we're adding adding hormones in that the body already has and just trying to help it regulate a little bit a little bit better.
Dr. William Dodd (28:26)
Absolutely. So what about you know what's what's our ultimate goal here?
Dr. Quinn Owen (28:36)
Yeah, yeah. So typically we like to use these hormones to help regulate the cycle. The the cycle is usually involves building that endometrial tissue or the tissue that comes out when you have your period, maintaining it and then ultimately shedding it, which is what we know as our period. so there the different ways that we use these pills kinda help to establish a timeline for that process to prevent bleeding that affects the patient's quality of life.
we do more detailed discussion of things. another episode of the podcast is Court Perception Recep Refresher with Dr. William Dodd and guest host Dr. Haley Lawrence. If you're interested in more of a deep dive into the hormonal methods of period regulation.
Dr. William Dodd (29:24)
Always love a good self citation. So
Dr. Quinn Owen (29:27)
Yeah,
check us out. but yeah, ultimately the goal would be to keep the patient physically healthy and then improve their quality of life. 'Cause like we mentioned at the beginning, this can affect lots of factors in life and in the quality of life of these patients and we don't want them to be going through it alone.
Dr. William Dodd (29:47)
Absolutely. Well, Dr. Owen, I've really enjoyed our conversation. I really appreciate the work that you've put into this and I think it's a really great overview. So thank you so much.
Dr. Quinn Owen (29:59)
Yeah, of course. Thank you for having me. This was fun.