Welcome back to the As Woman podcast. I'm your host, Dr. Natalie Crawford. And today, joining me is Emily Whitlock. We are doing one of your favorite episodes. This is Fertility Q&A, answering the questions that you have submitted. Hey, Em. Hi. Okay, let's get into it. First one says she is not TTC yet, but hopes to someday.

She is leaning into what you say about her period being a vital sign.

We love that.

She has really heavy periods and fills menstrual cup within a couple hours with lots of clots.

She said that doctors have really dismissed her.

She has PCOS, two to three days of spotting, five days of heavy, heavy bleeding, never pain or cramps. All labs have been normal. She's not on birth control. She got a salient sonogram that was also normal. She wants to know, could this just be the PCOS? Or maybe do you think that she might have a clotting abnormality? And what should she get tested for? Well, this is a good question. So I'm glad, first of all, that we have gotten some of the initial testing done and it sounds like we're at least having our problems taken seriously. Bleeding this much can be a sign that more is going on. So what are the top causes of having really heavy bleeding? So certainly abnormalities inside the uterus, so things like polyps or uterine fibroids are going to be really high on the list. These should be detected with a saline sonogram. So saline sonogram is where we do a regular vaginal ultrasound, but we actually combine it with a speculum exam or putting a small little catheter into the cervix and injecting saline or water so that we can push

the uterine walls apart and see the inside of the cavity. This is going to detect anything inside.

So one of the top things when patients have spotting or heavy bleeding is that they're often not getting

this exam and they may be missing polyps or small fibroids. So I'm glad that we've ruled anatomical

factors out. Third, on our anatomical list, though, sometimes can be ad fibroids. So I'm glad that we've ruled anatomical factors out. Third on an anatomical

list, though, sometimes can be adenomyosis. Adnomiosis is a chronic inflammatory disorder that is very

similar to endometriosis. If we think about endometriosis being implants of endometriol-like tissue

outside the uterus. Adnomyosis is implants of endometriol-like tissue outside the uterus. Adnomiosis is implants of endometrial-like tissue

in the muscle component of the uterus. So thinking about the uterus, the outside is called the

serosa. Then you've got this inner muscular layer called the myometriam. And the inside is the

mucosa. So in that myometrial, the muscular layer, you're not supposed to have that

endometrial layer like you have in that mucosal layer. So if those endometrial cells get in there,

that's highly inflammatory and should be visualized on ultrasound. But I've had some people

miss it or have to specifically ask about it. So especially if we've had births in the past, an IUD in the past, any uterine

surgery, those give away for those endometrial implants to get into that myometrial layer.

From there, a few other things to think about. Hypothyridism can cause really heavy periods. So it

could be hypothyroidism. Obviously making sure that we're not anemic. Sounds like hopefully we've been checked for that, but making sure that we're not anemic. And then certain clotting disorders, not in the way that make us clot, but that make us anticoagulated. So von Willa Brand's disease is one of the more common ones that we sometimes see here that women are not often checked for. Warning signs for this

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