Heavy menstrual bleeding linked to fatigue in menopausal women

Heavy menstrual bleeding linked to fatigue in menopausal women | Image Credit: © Antonioguillem - © Antonioguillem - stock.adobe.com.

Link between menstrual bleeding and fatigue

There is a link between heavy or prolonged menstrual bleeding and fatigue among menopausal women, according to a recent study published in Menopause, the journal of The Menopause Society.¹

Treatment is widely available for iron deficiency and related anemia, highlighting the benefits of early assessment and remediation. However, information from research, the lay press, and social media has not focused on bleeding problems during the menopause transition.

“This study highlights the need for greater clinical awareness of abnormal uterine bleeding, particularly given the increased frequency during the menopause transition and its association with low energy or fatigue symptoms,” said Stephanie Faubion, MD, MBA, medical director for The Menopause Society. “Educating women… is also needed.”

Study population and methodology

Premenopausal or perimenopausal women aged 42 to 52 years between 1996 and 1997 were included in the analysis.² Additional eligibility criteria included not being pregnant, lactating, or using exogenous sex hormones as baseline, alongside having a uterus and at least 1 intact ovary, with a menstrual cycle occurring in the prior 3 months.

Menstrual, gynecological, and medical histories were obtained through questionnaires completed by participants at baseline and every follow-up visit. Investigators also measured participant height and weight.

Menstrual calendars were completed by participants from enrollment through the tenth follow-up visit. In these calendars, patients recorded their menstrual bleeding for up to 10 years or until 2 years after their final menstrual period. Those with menstrual calendars for at least 6 months and at least 1 bleeding episode within a 6-month window were included in the current analysis.

Prespecified categories for spotting, light to moderate bleeding, and very heavy bleeding were provided on menstrual calendars for participants to record daily. These levels of bleeding included not requiring a sanitary product, sanitary product needing to be changed every 3 to 4 hours, and sanitary product needing to be changed every 1 to 2 hours for more than 4 hours per day, respectively.

Prolonged menstrual bleeding (PMB) included episodes lasting more than 8 days, while heavy menstrual bleeding (HMB) included very heavy bleeding for 3 or more days. Feeling worn out, tired, full of pep, and having energy were reported as outcomes of fatigue and vitality.

Participant demographics, menstrual bleeding, and fatigue

Of participants, 23.7% were Black, 50.5% White, 9.5% Chinese, 5.4% Hispanic, and 10.9% Japanese. A mean age of 47.3 years and mean body mass index of 47.3 were reported at the first study visit, and hormone therapy use was reported by 5.9% of participants and current smoking by 13.1%.

Depressive symptoms, anxiety symptoms, and sleep problems were reported in 24.9%, 17.6%, and 29.6% of participants, respectively. At least 1 HMB episode was reported in 20.7%, and at least 3 episodes in 5%. For PMB, these rates were 24.4% and 4.6%, respectively.

Fatigue was reported in approximately 1 in 4 participants at the first follow-up visit, while 26.6% reported feeling tired in the past 2 weeks and 24.2% feeling worn out in the same period. Having energy was reported in 50.2% and being full of pep in 50%.

Key results

The odds of feeling tired were approximately 30% higher among women with any HMB vs no HMB in the unadjusted analysis, with an odds ratio (OR) of 1.33. Similar, the OR for feeling worn out was 1.34. Reduced odds of having energy and being full of pep were also reported among these patients, with ORs of 0.78 and 0.81, respectively.

Among women reporting more episodes of HMB, the odds of feeling tired and the odds of feeling worn out were both increased by approximately 70%. Additionally, women with at least 3 cases of PMB in the last month experienced a more significant reduction in being full of pep, with an OR of 0.72. No other vitality or fatigue symptoms were linked to PMB.

These results indicated increased odds of low energy or fatigue among women with heavy or prolonged menstrual bleeding. The relationship between abnormal uterine bleeding (AUB) and fatigue remained when adjusting for potential cofounders.

“Given the increased frequency of AUB as women transition through menopause, greater clinical awareness of bleeding changes during this life stage, particularly heavy or prolonged bleeding, and associated low energy or fatigue symptoms, is warranted,” concluded investigators.

References

1. Are you just tired or are you menopause tired? March 11, 2025. Accessed March 12, 2025. https://menopause.org/press-releases/are-you-just-tired-or-are-you-menopause-tired
2. Harlow SD, Gold EB, Hood MM, Mukwege AA, Randolph JF, Greendale GA. Abnormal uterine bleeding is associated with fatigue during the menopause transition. Menopause. 2025;32(6). doi:10.1097/GME.0000000000002525