Heavy Menstrual Bleeding (Menorrhagia)
Heavy menstrual bleeding (HMB) is a common condition, also called heavy periods or Menorrhagia. Although heavy menstrual bleeding is usually defined as a total menstrual blood loss of more than 80 milliliters during every period, this can be difficult to measure. Therefore, the diagnosis is made on the basis of other signs such as:
- An unusual increase in menstrual blood loss
- Menstrual blood loss / a period that last longer than seven days
- Frequent flooding or menstrual loss not contained by pads or tampons
- Increase in the number of times you have to change pads or tampons (more than every four hours, or more than once during the night)
- Passing blood clots that are wider than 3cm; small stringy clots are common and normal
- Iron deficiency of the blood (anaemia) caused by heavy menstrual bleeding
Causes of Heavy Menstrual Bleeding
Dysfunctional Uterine Bleeding – If no abnormality in the uterus is found, the condition is called “dysfunctional uterine bleeding”. More than half of women with heavy menstrual bleeding have dysfunctional uterine bleeding. It is probably related with problem blood levels of female hormones that control menstruation principally oestrogen and progesterone. During the menstrual cycle, levels of these hormones change constantly.
Fibroids – These are benign (non-cancerous) growths of the muscle and connective-tissue cells in the wall of the uterus. They are found in up to one in three women. Although fibroids are often found in women with HMB, most of women with fibroids do not have HMB. In particular, small fibroids usually do not cause problems.
Endometrial polyps – These benign growths occur on the lining of the uterus. They may also lead to spotting between or after periods.
Endometrial hyperplasia – this is a thickening of the lining of the uterus (endometrium) that leads to heavier bleeding.
Adenomyosis – This is an enlargement of the uterus caused by growth of the endometrium into the wall of the uterus. Although the above conditions may cause, or be linked to, heavy menstrual bleeding, it is possible that heavy menstrual bleeding may occur in the absence of physical abnormalities of the uterus.
Uncommon causes of Heavy Menstrual Bleeding
- Thyroid imbalance
- Contraceptive intra-uterine devices (IUD)
- Some liver and kidney conditions
- Blood clotting disorders
- Endometrial cancer
Diagnosis and Tests
- An internal vaginal examination to feel the size of the uterus. A pap smear may be taken at the same time.
- A blood test for haemoglobin levels
- An Ultrasound scan to examine the lining of the uterus in women who have a higher risk of endometrial hyperplasia or uterine cancer. Ultrasound can also detect uterine fibroids, ovarian cysts and other pelvic abnormalities.
Treatments for Heavy Menstual Bleeding
Some years ago, surgical removal of the uterus (hysterectomy) was the only effective treatment, but now medicines are also available.
Surgical Treatments for Heavy Menstrual Bleeding/ Heavy Periods include:
- Endometrial ablation – This is the surgical removal or destruction of the lining of the uterus using a Hysteroscope, an instrument that is inserted into the cavity of the uterus through the vagina and cervix. The procedure is performed under general anesthesia, and women are usually able to go home the same day.
- Myomectomy – This is surgical removal of fibroids while retaining the uterus. Its precise effectiveness is reducing heavy menstrual bleeding has been a matter of debate.
- Hysterectomy –This is the removal of the uterus. The operation can be done in one of four ways.
- Abdominal Hysterectomy – removal of the uterus through the opening of the vagina.
- Vaginal Hysterectomy – removal of the uterus through the opening of the vagina.
- Laparoscopically assisted vaginal hysterectomy – removal of the uterus through the vagina will small cuts in the abdomen to assist the surgeon.
- Laparoscopic hysterectomy – removal of the uterus through small cuts in the abdomen.
The surgical method chosen depends on a range of issues, including the nature of a woman’s problem and her medical history.
Medical treatments for Heavy Menstrual Bleeding/ Heavy Periods
The following medications often have an effect during the first cycle they are used. There may be further improvement with subsequent cycles.
- Non-steroidal anti-inflammatory drugs (NSAIDs) – NSAIDs are medications that reduce heavy bleeding. They also have the advantage of relieving painful periods.
- Oral contraceptive pill – The pill usually reduces menstrual blood loss by a little more than a third. It may bring relief to women with painful periods.
- Oral Progesterone (progestogen) – oral progesterone reduces blood loss if it taken for 21 out of 28 days from day 5 to 25 of a woman’s cycle. It has the add advantage of producing regular cycles.
- Tranexamic acid – Tranexamic acid may reduce menstrual blood loss by about half. Tranexamic is a non-hormonal therapy that affects clotting mechanisms in the lining of the uterus. Tablets are only taken when the woman has heavy bleeding.
- Danazol – Danazol may reduce menstrual blood loss by about two-thirds and may cause some women to stop menstruating.
- Progestogen intrauterine device – Placed into the uterus via the cervix, this device steadily releases tiny amounts of progestogen. This keeps the endometrium then and inactive rather than increasing in thickness during the building up to ovulation. As the lining of the uterus does not increase, menstrual bleeding in reduced. Nearly all women will experience a large reduction in their blood loss. The treatment usually takes several months to achieve the desired effect. Added benefits are reliable contraception and no need to take tablets.
- Iron supplements for anaemia – A woman who bleeds heavily during every period can become anaemic, which is a low concentration of red cells in the blood or not enough haemoglobin in red blood cells. Anaemia can cause signs and symptoms such as pale skin, shortness of breath, tiredness and heart palpitations. Anaemia is usually treated with tablets containing iron.