How hormone imbalances cause heavy menstrual bleeding… and what to do about it

Our menstrual cycles are lately being referred to as our fifth vital sign. I love thinking about it this way because what we are experiencing throughout the month with our cycle can tell us so much information about our overall health.

Dealing with heavy bleeding, or menorrhagia, during your menstrual cycle is no walk in the park. Heavy periods can obviously disrupt daily life, affect quality of life, and even lead to anemia if not properly addressed. And often they are paired with strong menstrual cramping and pains. In this post, I will dive into why an imbalance in sex hormones can cause heavy bleeding, and then shed some light on some things we can do about it!

Let’s start with the basics. What you are bleeding every time you have your period is the tissue that builds up inside your uterine wall, called the endometrium. Our body creates the endometrium every cycle in preparation for a potential pregnancy. This protects the embryo and then later fetus, and provides it with necessary oxygen and nutrients. What regulates the growth and shedding of the endometrium? Your two main sex hormones: estrogen and progesterone.

Estrogen is a growth hormone that initiates the growth of the endometrium as you approach ovulation. Following ovulation (typically around day 15), progesterone significantly rises and cleans it up a bit, getting the lining ready for a potential fertilized egg. If there is no fertilized egg, then progesterone and estrogen drop at the end of your cycle, and this strong drop in progesterone stimulates your body to then release the endometrium, and you have your period! Below is a basic graphic that shows the flow of estrogen and progesterone throughout the menstrual cycle.

photo from: https://fundamentalnourishment.substack.com/p/you-have-been-lied-to-about-the-menstrual

Now that you know what should be happening, let’s get into how an imbalance between estrogen and progesterone can disrupt this delicate balance of growing and shedding the endometrium.

With heavy bleeding, the most common thing we’ll see with hormones:

• high levels of estrogen, with normal or low progesterone

• low levels of progesterone, with high or normal levels of estrogen

In both of these scenarios, we would consider this “estrogen dominance”, even if your estrogen is normal. It’s all about the ratio of these two.

If you have estrogen dominance this is why it might cause heavy bleeding:

• Since estrogen is a growth hormone, you’re going to build up more of that endometrium with higher levels, leading to heavy bleeding. If your problem is low progesterone, then you don’t have enough progesterone to clean up that lining, and therefore will have a thicker lining, leading to heavy bleeding.

If you’re confused, I like to compare it to getting a haircut. In this analogy, estrogen helps your hair grow, and then progesterone is getting a trim. If you want healthy hair, you need to keep up with getting regular trims. If you keep up with regular trims (which means a healthy balance of estrogen to progesterone), you only lose a little bit of hair from a trim each time you get it cut (regular bleed). However, if you wait a longggg time to get a trim (estrogen/progesterone imbalance), you’ll have way more damaged hair that your hairdresser now has to cut off (heavier bleed), and you leave with your hair 3 inches shorter than you wanted.

Now I’m ALL about testing and not guessing when it comes to hormones. Because treatment for estrogen dominance due to high levels of estrogen and treatment for estrogen dominance due to low levels of progesterone look very different. Luckily, it is possible to get these levels tested so that you can better understand your ratio of the two!

To best assess your ratio, you need to get serum (blood) progesterone and estradiol (main form for estrogen) tested 7 days post-ovulation. This is when progesterone should be at it’s peak, and is the best time to compare it’s levels to estrogen. This is often referred to as a “day 21” hormone blood draw, as day 21 is 7 days after ovulation in a “normal” 28 day cycle. But the reality is, normal cycles can be shorter or longer than 28 days, so to assume day 21 would be the correct day to run labs is not helpful. And for people with PCOS or hypothalamic amenorrhia that might have much longer or irregular cycles, they are likely ovulating much later in the cycle, if at all. In order to truly know when you ovulated, you need to track cervical mucus and basal body temperature (BBT) to confirm when ovulation occurred. The timing is very important with running these labs.

Once you have your levels, you can calculate your ratio here. Ideally, your progesterone:estradiol is between 100 and 500. Less than 100 would indicate estrogen dominance.

To dig even further into hormones, many of my clients opt into running the DUTCH test, which not only tells us progesterone and estrogen levels, but how estrogen is DETOXIFIED. If estrogen detoxification is slowed, this could also lead to estrogen dominance. Below is just a small piece of the DUTCH test, showing how the three main estrogens (estrone, estradiol, and estriol) are detoxified in phase 1 detoxification of the liver. It’s complicated, but valuable information to have.

While a lot of my recommendations get fairly individualized, especially when we have bloodwork and the DUTCH test to refer to, there are some general concepts and suggestions I will make when I see estrogen dominance.

1. Balance your blood sugar. Blood sugar rollercoasters can significantly impact your sex hormones, so this is ALWAYS a must. There’s a lot to explore when it comes to balancing your blood sugar, but below are a few basic tips to start:

   1. Switch from more processed/refined carbs (breads, crackers, pastas, baked goods) to more whole food, high fiber carbs (fruit, potatoes, winter squash, beans/lentils, etc.).

   2. Don’t eat naked carbs. This means, don’t eat carbohydrates by themselves. Eat them with protein or fat

   3. Make sure every meal has protein, fat, and fiber from high fiber carbs and/or non-starchy vegetables.

   4. Cut the unnecessary sugar from sugar-sweetened beverages

   5. Start your day with a very high protein/fat breakfast

2. Maintain a healthy gut microbiome. The microbes that make up your gut can influence how you detoxify estrogen. Also, the health of your gut influences metabolism and insulin signaling, which brings us back to tip #1 of balancing blood sugar! MANY things can positively and negatively impact our gut microbiome. When it comes to food, focus on high-fiber foods, less processed foods, eating slowly and chewing your food, and avoiding foods that very obviously cause inflammation in your body (this is very individualized). As much as I can, I always help my clients identify the root causes of their gut issues through their symptoms and testing (such as a stool test), and optimize their gut from there.

3. Consume phytoestrogens. You may have heard to avoid phytoestrogens if you have high estrogen. But consuming SOME phytoestrogen foods throughout the week can “tickle” the estrogen receptors in your body, and have a more gentle estrogen effect compared to your actual estrogen. This means a weaker estrogen signal, and can therefore help symptoms. Too much phytoestrogens might tickle those receptors too much, so there is a fine balance here. My top recommendations are 1 tbsp of ground flaxseed daily, and 2-3 servings of organic soy (tofu, tempeh, edamame, or miso) per week!

4. If your progesterone is low, really focus on increasing magnesium, zinc, and vitamin B6-rich foods to help boost progesterone production!

Please know that there are plenty more causes of heavy bleeding beyond sex hormone imbalances. This includes but is not limited to:

1. Thyroid issues

2. Adenomyosis or Endometriosis

3. Uterine polyps and fibroids

4. Copper IUD

5. Miscarriage

6. Pelvic infection

7. Liver disease

8. Coagulation disorders

The most important thing I want you to understand is that it’s important, and possible, to get to the bottom of WHY you are experiencing heavy bleeding, and you don’t have to keep suffering. If you suspect it’s hormone-related, don’t hesitate to schedule a free discovery call with me to see if I can support you in having a more enjoyable period!