"Before the hot flashes come the years no one warned you about."

It was 2017. I was in Shanghai for E-Teach Abroad, my English teaching placement business, and I was doing what I always did there — getting around by public transportation like a local. Packed subway car. Rush hour. No seats. Surrounded by hundreds of Chinese commuters, none of whom spoke English. I had my tampon in. I had my pad on. Because by that point in my perimenopause, I was wearing both of them simultaneously just to leave the house.

Within two hours, they were both saturated.

I felt the blood running down my leg before I fully understood what was happening. And then I did understand, and I had to sit down — right there, on the floor of a packed Shanghai subway car, in stained pants, surrounded by people I couldn’t communicate with, completely alone.

I got off at the next stop. I lay down on a bench in the subway station. I stayed there until the dizziness passed, until I felt like I could stand up without passing out. Then I went back to my hotel and changed, and I thought, as I had thought many times before: this is not normal. This cannot be normal.

I was 48 years old. I had no idea what was happening to my body.

This Is Not a Dramatic Story. This Is Perimenopause.

I want to be clear about what happened in that subway station: I was not being dramatic. I was not having a panic attack. I was bleeding through medical-grade absorbent products faster than my body could replace the fluid, alone in a foreign country, and I was lightheaded from blood loss.

That is what “heavy menstrual bleeding in perimenopause” actually looks like for some women. Not “heavier than usual periods.” Not “a little more crampy.” Full flooding events that no tampon-and-pad combination on earth can handle.

And here is what nobody had ever explained to me, not a single doctor in my life: this was physiologically predictable.

As your ovarian reserve declines in perimenopause, ovulation becomes erratic. Studies show roughly 20% of menstrual cycles in women aged 42-52 are anovulatory — meaning no egg is released. In irregular cycles, that rate climbs to 44-65%. And ovulation is the thing that matters here, because ovulation is what triggers progesterone production. No ovulation means no corpus luteum (the temporary structure in your ovary that makes progesterone). No corpus luteum means no progesterone.

And estrogen just keeps going. Your ovaries are still producing it, often in wild swings. But without progesterone to organize the cycle — to cap the endometrial growth, to signal an orderly shed — your uterine lining just keeps building. And building. And then when it finally sheds, it sheds everything, all at once, in a chaotic, clotty flood.

This is the direct result of progesterone deficiency, not “too much estrogen.” Estrogen is doing exactly what it always does. It’s just got no counterpart anymore. And nobody warned us.

What I Finally Did About It

I had the NovaSure ablation. I chose to do it under general anesthesia in a hospital, not as an office procedure — both options exist, but I wanted to be fully out.

NovaSure works like this: a triangular mesh electrode is passed through your cervix into your uterine cavity, where it expands to conform to the shape of your uterus. Then it delivers controlled radiofrequency energy for approximately 90 seconds. The device monitors tissue resistance and shuts off automatically when your endometrium is sufficiently destroyed. The procedure took less than two minutes of actual energy delivery.

I woke up from anesthesia and the cramping was significant. More than I expected. I want to be honest about that because most of the marketing for this procedure makes it sound like you’ll be back at yoga by the weekend. The cramping when I came out of anesthesia was real and bad. It passed. But it was there.

Within a few months: no more periods. The flooding events that had been controlling my life — that had put me on a subway floor in Shanghai — were gone.

I am a strong advocate for this procedure. If you have completed your family and you have this problem, I wish someone had put this option on my radar years earlier. 82-97% of women experience significant bleeding reduction; 30-75% stop having periods entirely. Over 500,000 NovaSure procedures are performed in the United States each year. This is not fringe medicine. This is mainstream gynecology that millions of women don’t know exists until they’re already in crisis.

There is one important nuance I’ll get to at the end — about estrogen therapy and the cornua — but the point stands: ablation changed my life.

Then I Found Out About the Hemochromatosis

Here is where the story gets genuinely strange.

After the ablation, after the periods stopped, my iron levels started climbing. My doctor flagged elevated ferritin during routine labs. I had a 23andMe Health Add-on done as part of my deep-dive into my genetics. And there it was: HFE gene variants. Hereditary hemochromatosis.

Hemochromatosis is a genetic condition where your body absorbs too much iron from food and stores it in your organs — your liver, your heart, your joints. Left unchecked for long enough, it causes organ damage. It’s the most common inherited disorder in people of Northern European ancestry (specifically Celtic and Northern English lineage — which happens to be mine). And it is profoundly underdiagnosed in women, for one specific reason: menstruation naturally removes iron from the body. Women who bleed heavily every month are inadvertently doing therapeutic phlebotomy on themselves.

Sit with that for a moment.

The flooding events that put me on the floor of a subway car in Shanghai were simultaneously preventing iron overload in my organs.

My dangerously heavy periods — the most medically alarming symptom I experienced in perimenopause — were also the reason I didn’t develop liver damage from a genetic condition I didn’t know I had.

This is the kind of thing that makes you appreciate how complicated biology is, and how a “bad” thing can be doing a job you had no idea needed doing.

I now monitor my iron levels. I adjust diet as needed. No phlebotomy required at the moment. But I couldn’t have managed it if I hadn’t known it existed — and I wouldn’t have known it existed without the genetic test.

”What If I’d Had the Ablation at 25?”

I’ve thought about this a lot. I was near-anemic my whole life. I was turned away from donating blood in my 20s and 30s because my levels were too low. I was so tired during high school that I couldn’t get through basketball tryouts. I always assumed I was just… like that. A tired person.

Now I wonder if a significant portion of my lifelong fatigue was from blood loss anemia — from periods that were already heavy before perimenopause turned them catastrophic. I wonder what those years could have been like with normal iron levels. More energy. Less brain fog. A body that wasn’t quietly hemorrhaging resources every month.

What if I’d had the ablation at 27? When I was done having children, done with my family-building phase, and simply didn’t need a uterine lining anymore?

And then I catch myself, because — hemochromatosis. If I’d stopped bleeding at 27, the iron would have started accumulating then. Would we have caught it? Would anyone have looked? Probably not. The condition wasn’t on anyone’s radar. The paradox holds: the thing that was hurting me was also protecting me, right up until medicine was ready to find the underlying problem.

The answer to “what if I’d done this sooner?” is more complicated than I initially thought. Which is exactly how biology usually works.

What You Need to Know If This Is You

Heavy menstrual bleeding in perimenopause is not just “a bad period phase you have to survive.” It is a medical situation, and there are real options at every stage.

Before ablation — medical management options include:

Oral micronized progesterone in the luteal phase — this can address the root cause (progesterone deficiency driving anovulatory heavy bleeding) and is worth trying first
Tranexamic acid — a medication that reduces blood loss volume during heavy periods
NSAIDs (like ibuprofen) — reduce prostaglandins that contribute to heavy bleeding
The Mirena IUD — releases low-dose local progesterone to thin the endometrium; highly effective for many women with heavy bleeding and doesn’t affect systemic hormone levels
Hormonal birth control — can regulate cycles in perimenopause if other options are contraindicated

When you’re considering ablation:

You’ve completed your family (ablation significantly reduces fertility; pregnancy after ablation is dangerous)
Medical management hasn’t been sufficient
You’re done with monitoring whether you ovulated this month or not
You want your life back

After ablation — things to know:

First: ablation rarely destroys 100% of the endometrium. Small islands of tissue can survive, particularly in the cornua — the upper horn-shaped corners of the uterus where the fallopian tubes enter. This matters if you’re on estrogen therapy. The British Menopause Society currently recommends that women who have had ablation still use combined HRT (estrogen plus progesterone) rather than estrogen alone, because you cannot assume all endometrial tissue is gone without invasive testing. Endometrial cancer has been documented in women given estrogen-only HRT after ablation.

This is why I am getting a transvaginal ultrasound to check the cornual regions. It’s not alarmist. It’s sensible monitoring. Ask your doctor about it.

Second: you will no longer know when you’ve reached menopause. The standard definition — 12 consecutive months without a period — is completely unreliable after ablation, because you may not be having periods anyway. To know where you are in the menopausal transition, you need bloodwork: FSH, estradiol, and AMH. And you need to pay attention to symptoms — hot flashes, sleep disruption, vaginal dryness, brain fog — because those happen regardless of whether your endometrium is intact.

Third: if you have Northern European ancestry and you’ve had heavy periods your whole life, please get your ferritin tested post-ablation. Not as a scare tactic. Just as information you deserve to have.

I Wish I’d Known Sooner

I am not angry that I didn’t know any of this at 35. I’m aware that the medical system wasn’t particularly interested in explaining perimenopausal physiology to women — and most of what we now know about HRT, progesterone, and menopause management has only entered mainstream awareness in the past five to ten years.

But I am someone who runs toward information. I want to know what is happening in my body and why. And for too many years, I was lying on subway benches in foreign countries thinking I was somehow an anomaly, when what was actually happening was physiologically predictable, medically manageable, and thoroughly documented — just never communicated.

If you’re having flooding events — genuinely soaking through a tampon and a pad within two hours, which is the clinical threshold for abnormal uterine bleeding — you are not being dramatic, and you are not an outlier. You are having a medical experience that deserves medical attention.

Get the bloodwork. Talk to a doctor who takes this seriously. Consider the options. And if you’re done having children and this is your reality, please know that NovaSure exists, it works for the majority of women who have it, and it is not as scary as it sounds.

I wish someone had told me that when I was standing in a subway station in Shanghai, willing myself not to pass out.

Annette Thompson is 57, the founder of adoption.com, and a menopause advocate writing about evidence-based women’s health.