When a doctor dismissed your symptoms: what to do next

If a doctor dismissed your symptoms, bring a written record to the next visit. Record when bleeding began and ended, the heaviest hour, how often you changed a pad or tampon, whether you passed clots, and whether you felt fatigue or shortness of breath. Heavy menstrual bleeding has several listed causes, including fibroids and changes during perimenopause [1][2][3]. Ask which causes and possible effects of blood loss have been assessed.

What should you write down?

A uterine fibroid, also called a leiomyoma, is a growth made of muscle and tissue that develops in the uterine wall or on its surface [1]. Cleveland Clinic describes intramural, submucosal, subserosal, and pedunculated types, based on where they are found [1]. Imaging is used to find or assess fibroids [1].

The symptom list includes excessive or painful menstrual bleeding, bleeding between periods, lower-abdominal fullness or bloating, frequent urination, pain during sex, low back pain, constipation or rectal pressure, chronic vaginal discharge, incomplete bladder emptying, and increased abdominal distention [1]. Write down what happened, when it happened, and how it affected you.

Perimenopause can include irregular periods, heavier or lighter periods, mood changes, low libido, hot flashes, night sweats, vaginal dryness with discomfort during sex, urinary urgency, and trouble sleeping [3]. During perimenopause, cycles can become longer or shorter, and bleeding can become heavier or lighter [3].

Iron-deficiency anemia is a blood disorder usually caused by bleeding, and people with heavy periods have increased risk [4]. Symptoms include fatigue, headaches, irritability, muscle cramps, pale skin, pica, shortness of breath, a sore tongue, spoon-shaped nails, and a fast heart rate [4]. Put those symptoms in your record if you have them.

Why should fibroids be part of the question?

In an ultrasound-screened cohort of 1,364 women, the estimated cumulative incidence of uterine fibroid tumors by age 50 was over 80% for Black women and nearly 70% for white women [5]. Among premenopausal women in that cohort, 35% had a previous fibroid diagnosis. Among premenopausal women without a previous diagnosis, 51% had ultrasound evidence of fibroid tumors [5].

Baird 2003 reports that fibroids develop at earlier ages in Black women than in white women, and that most Black and white women in the United States develop them before menopause [5]. Eltoukhi 2013 reports earlier diagnosis, greater likelihood of symptoms, and greater fibroid size and growth rates among African American women compared with white women [6].

Use that information to ask:

“Could fibroids be part of the assessment for my bleeding and other symptoms?”

Which bleeding details show that it is heavy?

Cleveland Clinic lists bleeding that lasts longer than seven days, soaking through a pad or tampon every hour for several hours, needing more than one pad at a time, changing protection during the night, and passing clots the size of a quarter or larger several times a day as signs of heavy menstrual bleeding [2].

Write down:

• The date bleeding started and stopped.
• The heaviest hour.
• How often you changed a pad or tampon during that hour.
• Whether you needed more than one pad at a time.
• Whether you changed protection during the night.
• Whether you passed clots the size of a quarter or larger several times a day.
• Whether bleeding happened between periods or after sex.
• Whether periods came less than 21 days apart.
• Whether you had fatigue, shortness of breath, or other listed anemia symptoms [2][3][4].

You can open the appointment with the sentence that matches your record:

“My bleeding lasted longer than seven days.”

“I soaked through a pad or tampon every hour for several hours.”

“I needed more than one pad at a time.”

“I changed my protection during the night.”

“I passed clots the size of a quarter or larger several times a day.”

“The bleeding happened between periods.”

“The bleeding happened after sex.”

“My periods came less than 21 days apart.”

What is the urgent bleeding threshold?

Cleveland Clinic says that soaking at least two pads or tampons each hour and continuing across two to three consecutive hours calls for prompt professional evaluation [2]. If your record reaches that threshold, say:

“I soaked at least two pads or tampons each hour for two to three hours in a row.”

Cleveland Clinic’s perimenopause guidance also says to contact a provider about bleeding that is very heavy, soaks a pad every one to two hours, lasts longer than usual, happens between periods, follows sex, or occurs when periods come less than 21 days apart [3].

Which tests can you ask about?

Tests used to find or assess fibroids include ultrasonography, magnetic resonance imaging, computed tomography, hysteroscopy, hysterosalpingography, sonohysterography, and laparoscopy [1].

For heavy menstrual bleeding, the listed tests include pelvic ultrasound, blood tests, transvaginal ultrasound, MRI, Pap testing, cervical culture, endometrial biopsy, sonohysterogram, and hysteroscopy [2].

Ask:

“Do I need a pelvic or transvaginal ultrasound for this bleeding?”

“Which test would assess possible fibroids?”

“Which test would assess the uterine lining?”

“Do I need blood work for iron-deficiency anemia?”

Cleveland Clinic lists ferritin and total iron-binding capacity among blood work for iron-deficiency anemia [4]. Ask:

“Should my blood work include ferritin and total iron-binding capacity?”

Could this be perimenopause?

Perimenopause is the transition before menopause, when estrogen levels start to decrease [3]. It usually starts in the mid-40s, though it may begin as early as the mid-30s or as late as the mid-50s [3]. Menopause is reached after 12 months in a row without a menstrual period [3].

Perimenopause can bring heavier or lighter bleeding and longer or shorter cycles [3]. Heavy menstrual bleeding also has a list of possible causes that includes fibroids, polyps, adenomyosis, infections, pregnancy complications, bleeding disorders such as von Willebrand disease, liver or kidney disease, cancers, and some medications, including blood thinners [2].

Ask:

“What makes you think this is perimenopause?”

“Which other listed causes of heavy bleeding have been assessed?”

Cleveland Clinic says perimenopause is usually identified from symptoms, age, medical history, and a physical exam. Follicle-stimulating hormone testing can help, but hormone levels rise and fall erratically during perimenopause [3]. Ask:

“Would follicle-stimulating hormone testing help in my case, given that hormone levels can change during perimenopause?”

What if you are told to wait?

Cleveland Clinic says small fibroids often need no treatment [1]. If you are told to wait, write down the reason given and ask what the waiting period is meant to establish.

Ask:

“What are we waiting to learn?”

“Which change means I should return sooner?”

“Do I need blood work now?”

“Do I need imaging now?”

“What is the next step if this continues?”

Cleveland Clinic lists iron supplements, NSAIDs, birth control, hormone therapy, GnRH agonists, desmopressin, tranexamic acid, hysteroscopy, a D and C, myomectomy, uterine artery embolization, endometrial ablation, and hysterectomy among treatments for heavy menstrual bleeding [2].

Ask:

“Is this intended to manage bleeding, address anemia, or assess a fibroid?”

“What does this treatment do, and what does it not do?”

What should you bring to the appointment?

What to do next

1. Write down when bleeding started and stopped, the heaviest hour, pad or tampon changes, clots, pain, and other symptoms before the appointment.
2. Open with the threshold sentence that matches your record, such as, “I soaked a pad every hour for several hours” [2].
3. Ask whether you need pelvic or transvaginal ultrasound and blood work for anemia [2][4].
4. Ask whether blood work should include ferritin and total iron-binding capacity [4].
5. If perimenopause is suggested, ask which other listed causes of heavy bleeding have been assessed [2][3].
6. Ask, “What are we waiting to learn, and what change means I should return sooner?”
7. If you are soaking at least two pads or tampons each hour for two to three hours in a row, seek prompt professional evaluation [2].
8. If you feel short of breath or unusually tired, say so directly and ask whether blood loss and iron-deficiency anemia need assessment [2][4].
9. Write down the answers, the reason for waiting, and the next step if bleeding continues.

Related on Ruby: fibroid symptoms explained and heavy periods during perimenopause.

Sources

1. Cleveland Clinic, Uterine fibroids. https://my.clevelandclinic.org/health/diseases/9130-uterine-fibroids
2. Cleveland Clinic, Menorrhagia (heavy menstrual bleeding). https://my.clevelandclinic.org/health/diseases/17734-menorrhagia-heavy-menstrual-bleeding
3. Cleveland Clinic, Perimenopause. https://my.clevelandclinic.org/health/diseases/21608-perimenopause
4. Cleveland Clinic, Iron-deficiency anemia. https://my.clevelandclinic.org/health/diseases/22824-iron-deficiency-anemia
5. Baird 2003, High cumulative incidence of uterine leiomyoma in black and white women, PubMed. https://pubmed.ncbi.nlm.nih.gov/12548202/
6. Eltoukhi 2013, The health disparities of uterine fibroids for African American women, PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC3874080/