A Functional Medicine Menorrhagia Protocol: Comprehensive Testing, Therapeutic Diet, and Supplements

The average menstrual cycle ranges from 23-39 days, beginning with a period lasting 2-7 days. Abnormal uterine bleeding, or menorrhagia, is one of the leading causes of outpatient gynecological visits, accounting for up to 30% of office visits annually in the United States. Menorrhagia is associated with poorer quality of life and productivity and high healthcare costs. At least 50-70% of hysterectomies before age 60 can be attributed to menorrhagia. (24)

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What Is Menorrhagia?

Menorrhagia is excessively heavy or prolonged menstrual bleeding. Heavy bleeding refers to periods that last longer than seven days or blood loss of over 80 mL during each period. Women who report needing to change a pad or tampon every 2-3 hours and/or passing clots at least the size of a quarter are likely to have menorrhagia. (24)

Symptoms of Menorrhagia

Signs and symptoms of menorrhagia include:

Soaking through at least one pad or tampon every hour for several hours in a row
Needing to double up on pads to control menstrual flow
Needing to change pads and tampons during the night
Bleeding for longer than one week
Passing blood clots the size of a quarter or larger
Needing to restrict normal activities due to heavy menstrual flow
Constant lower abdominal pain during periods

The most common cause of iron deficiency anemia (IDA) in menstruating females is blood loss due to heavy periods. Patients with menorrhagia, therefore, may experience signs and symptoms of anemia, including (7):

Fatigue
Exercise intolerance, including shortness of breath and muscle weakness
Skin pallor
Headaches
Dizziness
Cold intolerance

What Causes Menorrhagia?

Hormonal imbalances, particularly excess estrogen relative to progesterone (estrogen dominance), can lead to abnormal uterine bleeding. During a healthy menstrual cycle, a delicate balance between estrogen and progesterone builds the lining of the uterus (endometrium), which is then shed during menstruation. Hormonal imbalances can lead to thickening of the endometrium, causing heavy menstrual bleeding. Factors such as thyroid dysfunction, polycystic ovarian syndrome (PCOS), insulin resistance, and perimenopause can disrupt the delicate hormonal balance, resulting in menorrhagia. Additionally, anovulatory menstrual cycles may result in menorrhagia due to an associated progesterone deficiency that occurs when ovulation does not occur.

Pelvic pathologies that can cause abnormal, heavy bleeding include fibroids, polyps, adenomyosis, endometrial hyperplasia, and cervical or uterine cancer. Pregnancy complications, sexually transmitted infections, pelvic inflammatory disease, and endometritis can also be responsible. Menorrhagia is a common side effect of nonhormonal contraceptive intrauterine devices (IUDs). (15)

Systemic conditions, including liver disease, kidney disease, and clotting disorders, can also cause heavy menstrual bleeding (16).

Medications that interact with platelets and coagulation factors should not be overlooked as a cause of menorrhagia. Some medications that can cause menorrhagia as an adverse effect include anticoagulants and blood thinners, oral contraceptive medications, tamoxifen, tricyclic antidepressants, antipsychotics, and corticosteroids. (24)

Functional Medicine Labs to Test for Root Cause of Menorrhagia

Standard guidelines for the evaluation of menorrhagia encourage ordering and performing the following tests and imaging (15, 21):

hCG to rule out pregnancy
CBC with an iron panel to assess the extent of blood loss and iron status
Coagulation screen to rule out clotting disorders, as indicated by patient history
TSH, as a thyroid function screen
STI screening for gonorrhea and chlamydia
Pelvic exam and pap smear to assess for vaginal and cervical abnormalities, including cervical cancer
Pelvic imaging, which may include ultrasound, MRI, or hysteroscopy
Endometrial biopsy to rule out uterine cancer, if indicated by lab and imaging results

These test results are often within normal units, proving unhelpful in determining the underlying cause of menorrhagia. A functional medicine doctor, therefore, often utilizes more advanced specialty testing to better understand the imbalances in physiology and biochemistry contributing to heavy menstrual bleeding.

Comprehensive Hormone Testing

The DUTCH Cycle Mapping test tracks the patterns of estrogen and progesterone throughout a woman's menstrual cycle to get a complete picture of a woman's follicular, ovulatory, and luteal phases of her menstrual cycle. Using this test can be exceptionally helpful in finding hormonal patterns suggestive of estrogen dominance, PCOS, anovulation, or other reproductive hormone imbalances that can contribute to heavy bleeding.

Comprehensive Thyroid Panel

Research suggests that measuring only TSH can miss 7% of patients with overt thyroid dysfunction; this is why functional medicine doctors tend to order at least three markers of thyroid health when screening for thyroid disease. A complete thyroid panel should include at least TSH, free T3, and free T4. Often, these panels will also have additional thyroid hormones and antibodies to better assess the thyroid signaling cascade and catch subclinical thyroid disease early. (4)

Comprehensive Stool Test

Hormonal imbalances are often connected to intestinal dysbiosis and slow motility. The estrobolome is a collection of bacteria in the gut capable of metabolizing and modulating the body's circulating estrogen. Dysbiosis within the estrobolome cause elevations of beta-glucuronidase, an enzyme that helps reabsorb estrogen back into circulation. Similarly, constipation can inhibit the normal elimination of excess estrogen from the body, contributing to estrogen dominance.

Balancing hormones can prove to be very difficult in patients with gut dysfunction. A comprehensive stool analysis looks at many biomarkers related to the gut's overall health and microbiome to pinpoint how gastrointestinal imbalances may contribute to hormonal and menstrual health.

Micronutrient Testing

Imbalances in essential macro- and micronutrients can impact the menstrual cycle by impairing critical hormone production and metabolism pathways, causing PMS, digestive symptoms, and irregular bleeding patterns. A micronutrient panel measures essential vitamins, minerals, antioxidants, amino acids, and fatty acids for a comprehensive nutritional assessment, allowing doctors to tailor dietary and supplemental recommendations based on the patient's cellular needs.

Cardiometabolic Panel

Because metabolic issues can contribute to irregular and heavy periods, ordering a CMP and diabetes panel is helpful in screening for liver disease, kidney disease, and problems with glucose metabolism.

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Conventional Treatment for Menorrhagia

According to the American Academy of Family Physicians, medical therapy options are limited for treating menorrhagia. Commonly recommended treatments, which preserve fertility, include continuous oral administration of progestin and the levonorgestrel-releasing IUD. Surgical options include hysterectomy and endometrial ablation for women in which future childbearing is not desired. (1)

Functional Medicine Treatment Protocol for Menorrhagia

Fortunately, functional medicine offers other avenues to explore for treating menorrhagia, reestablishing healthy menstrual cycles, and improving quality of life. Combining diet, lifestyle, and targeted natural supplements can reestablish healthy hormonal patterns and address other underlying causes of heavy bleeding.

Regular aerobic and resistance training exercise, followed by appropriate time for rest and recovery, has been shown to positively affect circulating estrogen, progesterone, and testosterone levels. Additionally, exercise is essential for supporting cardiovascular and metabolic health, improving insulin sensitivity, reducing blood sugar, and helping to maintain a healthy weight. (11)

Therapeutic Diet and Nutrition Considerations for Menorrhagia

Women should be encouraged to follow a whole foods diet rich in whole grains, fruits, vegetables, legumes, quality fats, nuts, and seeds. Foods high in omega-3 fatty acids, such as fatty fish, flaxseeds, and hemp seeds, should be emphasized to promote the preferred prostaglandin pathways that reduce uterine inflammation and heavy flows. (15)

Additionally, iron-rich foods should be incorporated into the diet, especially during menstruation, to offset iron loss that occurs through bleeding. Examples of iron-rich foods include red meat, liver, eggs, tofu, and dark chocolate. Vitamin C-rich foods can enhance the absorption of iron by the gastrointestinal tract. Conversely, avoid eating iron-rich foods or taking iron supplements with foods highly concentrated with phytates, polyphenols, tannins, calcium, and oxalates - all known inhibitors of iron absorption. (7)

Supplements Protocol for Menorrhagia

Many dietary supplements and botanicals are available to support women's health and healthy menstruation. Below is an example of a supplement protocol that could be recommended to patients in clinical practice.

Slow Flow™

Vitanica's Slow Flow™ formula combines various vitamins, bioflavonoids, and astringent and uterine-tonifying herbs to support a normal menstrual flow. Vitamins A, K, C, and bioflavonoids are evidence-based nutrients that support a healthy menstrual flow and alleviate menorrhagia. The four botanical herbs included in the formula - yarrow, cranesbill, Shepherd's purse, and ginger - reduce inflammation, stop bleeding, and strengthen the uterus to promote uterine health and reduce menstrual bleeding. (14)

Dose: 2 capsules daily, increased up to 3 capsules twice daily during menses