Menorrhagia is the medical term for menstrual periods with abnormally heavy or prolonged bleeding in consecutive cycles. Although heavy menstrual bleeding is a common concern among premenopausal women, it does not mean there is anything seriously wrong.
With menorrhagia, every period you have causes enough blood loss and cramping that you can’t maintain your usual activities. If you have menstrual bleeding so heavy that you dread your period, talk with your doctor. There are many effective treatments for menorrhagia.
A good indication that your blood loss is excessive is if:
- you feel you are using an unusually high number of tampons or pads
- you experience flooding (heavy bleeding) through to your clothes or bedding
- you need to use tampons and towels together
- Symptoms of anemia, such as tiredness, fatigue or shortness of breath
When to see a doctor
Seek medical help before your next scheduled exam if you experience:
- Vaginal bleeding so heavy it soaks at least one pad or tampon an hour for more than a few hours
- Bleeding between periods or irregular vaginal bleeding
- Any vaginal bleeding after menopause
What causes heavy periods?
In most cases, no underlying cause of heavy periods is identified.
A number of conditions may cause menorrhagia.
Common causes include:
- cervical or endometrial polyps – non-cancerous growths in the lining of the womb or cervix (neck of the womb)
- endometriosis– when small pieces of the womb lining are found outside the womb, such as in the fallopian tubes, ovaries, bladder or vagina (although this is more likely to cause painful periods)
- uterine fibroids – non-cancerous growths in the womb that can cause pelvic pain
- Non hormonal intrauterine contraceptive devices Copper T (IUCD) (also known as “the coil”) – blood loss may increase by 40-50% after an IUCD is inserted.
- Pelvic Inflammatory Disease (PID) – an ongoing infection in the pelvis that can cause pelvic pain, fever and bleeding after sexual intercourse or between periods
- Polycystic Ovarian Syndrome (PCOS)– women with PCOS typically have a number of cysts in their ovaries
- blood clotting disorders such as Von Willebrand’s disease
- adenomyosis – when glands from the lining of the uterus become embedded in the uterus muscle
- An underactive thyroid (Hypothyroidism) – this may cause fatigue, constipation, intolerance to cold, and hair and skin changes
- Cancer of the womb (although it is rare)
Menorrhagia is most often due to a hormone imbalance that causes menstrual cycles without ovulation. In a normal cycle, the release of an egg from the ovaries stimulates the body’s production of progesterone, the female hormone most responsible for keeping periods regular. When no egg is released, insufficient progesterone can cause heavy menstrual bleeding.
Menstrual cycles without ovulation (anovulatory cycles) are most common among two separate age groups:
- Adolescent girls who have recently started menstruating.Girls are especially prone to anovulatory cycles in the first year after their first menstrual period (menarche).
- Older women approaching menopause.Women ages 40 to 50 are at increased risk of hormonal changes that lead to anovulatory cycles.
Excessive or prolonged menstrual bleeding can lead to other medical conditions, including:
- Iron deficiency anemia.In this common type of anemia, your blood is low in hemoglobin, a substance that enables red blood cells to carry oxygen to tissues. Low hemoglobin may be the result of insufficient iron.
Menorrhagia may decrease iron levels enough to increase the risk of iron deficiency anemia. Signs and symptoms include pale skin, weakness and fatigue. Although diet plays a role in iron deficiency anemia, the problem is complicated by heavy menstrual periods.
Most cases of anemia are mild, but even mild anemia can cause weakness and fatigue. Moderate to severe anemia can also cause shortness of breath, rapid heart rate, lightheadedness and headaches.
- Severe pain.Along with heavy menstrual bleeding, you might have painful menstrual cramps (dysmenorrhea). Sometimes the cramps associated with menorrhagia are severe enough to require prescription medication or a surgical procedure.
If your periods are so heavy that they limit your lifestyle, make an appointment with your doctor or the specialist.
Here’s some information to help you prepare for your appointment and know what to expect from your specialist or the doctor.
What you can do
To prepare for your appointment:
- Ask if there are any pre-appointment instructions.Your doctor may ask you to track your menstrual cycles on a calendar, noting how long they last and how heavy the bleeding is.
- Write down any symptoms you’re experiencing,and for how long. In addition to the frequency and volume of your periods, tell your doctor about other symptoms that typically occur around the time of your period, such as breast tenderness, menstrual cramps or pelvic pain.
- Write down key personal information,including any recent changes or stressors in your life. These factors can affect your menstrual cycle.
- Make a list of your key medical information,including other conditions for which you’re being treated and the names of medications, vitamins or supplements you’re taking.
- Write down questions to ask your doctor,to help make the most of your time together.
For menorrhagia, some basic questions to ask your doctor include:
- Are my periods abnormally heavy?
- Do I need any tests?
- What treatment approach do you recommend?
- Are there any side effects associated with these treatments?
- Will any of these treatments affect my ability to become pregnant?
- Are there any lifestyle changes I can make to help manage my symptoms?
- Could my symptoms change over time?
Don’t hesitate to ask any other questions that occur to you during your appointment.
What you can do in the meantime
While you wait for your appointment, check with your family members to find out if any relatives have been diagnosed with bleeding disorders. In addition, start jotting down notes about how often and how much you bleed over the course of each month. To track the volume of bleeding, count how many tampons or pads you saturate during an average menstrual period.
Your doctor will most likely ask about your medical history and menstrual cycles. You may be asked to keep a diary of bleeding and nonbleeding days, including notes on how heavy your flow was and how much sanitary protection you needed to control it.
Your doctor will do a physical exam and may recommend one or more tests or procedures such as:
- Blood tests.A sample of your blood may be evaluated for iron deficiency (anemia) and other conditions, such as thyroid disorders or blood-clotting abnormalities.
- Pap test.In this test, cells from your cervix are collected and tested for infection, inflammation or changes that may be cancerous or may lead to cancer.
- Endometrial biopsy (Pipelle).Your doctor may take a sample of tissue from the inside of your uterus to be examined by a pathologist.
- Ultrasound scan.This imaging method uses sound waves to produce images of your uterus, ovaries and pelvis.
Based on the results of your initial tests, your doctor may recommend further testing, including:
- This exam involves inserting a tiny camera through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus.
Doctors can be certain of a diagnosis of menorrhagia only after ruling out other menstrual disorders, medical conditions or medications as possible causes or aggravations of this condition.
Specific treatment for menorrhagia is based on a number of factors, including:
- Your overall health and medical history
- The cause and severity of the condition
- Your tolerance for specific medications, procedures or therapies
- The likelihood that your periods will become less heavy soon
- Your future childbearing plans
- Effects of the condition on your lifestyle
- Your opinion or personal preference
Drug therapy for menorrhagia may include:
- Iron supplements.If you also have anemia, your doctor may recommend that you take iron supplements regularly. If your iron levels are low but you’re not yet anemic, you may be started on iron supplements rather than waiting until you become anemic.
- Nonsteroidal anti-inflammatory drugs (NSAIDs).NSAIDs, such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).
- Tranexamic acid.Tranexamic acid (Lysteda) helps reduce menstrual blood loss and only needs to be taken at the time of the bleeding.
- Oral contraceptives.Aside from providing birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding.
- Oral progesterone.When taken for 10 or more days of each menstrual cycle, the hormone progesterone can help correct hormone imbalance and reduce menorrhagia.
- The hormonal IUD (Mirena).This intrauterine device releases a type of progestin called levonorgestrel, which makes the uterine lining thin and decreases menstrual blood flow and cramping.
If you have menorrhagia from taking hormone medication, you and your doctor may be able to treat the condition by changing or stopping your medication.
You may need surgical treatment for menorrhagia if drug therapy is unsuccessful. Treatment options include:
- Dilation and curettage (D&C).In this procedure, your doctor opens (dilates) your cervix and then scrapes or suctions tissue from the lining of your uterus to reduce menstrual bleeding. Although this procedure is common and often treats acute or active bleeding successfully, you may need additional D&C procedures if menorrhagia recurs.
- Uterine artery embolization.For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply.
During uterine artery embolization, the surgeon passes a catheter through the large artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with microspheres made of plastic.
- This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
- Endometrial ablation.Using a variety of techniques, your doctor permanently destroys the lining of your uterus (endometrium) eg. Novasure. After endometrial ablation, most women have much lighter periods. Pregnancy after endometrial ablation can put your health at risk — if you have an endometrial ablation, you should use reliable or permanent contraception until menopause.
- Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. Hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.
Except for hysterectomy, these surgical procedures are usually done either local anaesthetic or general anaesthetic . Although you may need a general anaesthetic, it’s likely that you can go home later on the same day.
When menorrhagia is a sign of another condition, such as thyroid disease, treating that condition usually results in lighter periods.
Dr. A S Arun MD DNB CCST, FRCOG, FRANZCOG
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