Some women unfortunately suffer from heavy bleeding during their menstrual period regularly; Menorrhagia is the medical term used to describe those heavy periods. Sometimes, the periods are prolonged as well; the term used then is polymenorrhea. Some women suffer from both heavy and prolonged periods.
The normal menstrual flow occurs every 21 to 35 days usually lasting around 4-5 days. It has been estimated that the menstrual blood loss is on average between 30-40ml yet up to 80 ml is accepted as normal. But if the total blood loss exceeds 80 mls which is about 6 tablespoons then the condition is described as menorrhagia.
What are the symptoms of menorrhagia?
1. Menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours.
2. Having to change the sanitary protection during the night.
3. Menstrual periods lasting longer than seven days.
4. The presence of large clots within the menstrual flow
5. Constant pain in your lower abdomen during menstrual periods that can be severe enough to stop you from getting out or going to work.
6. Tiredness, fatigue or shortness of breath and having to change your regular lifestyle to cope with your heavy periods.
There are a number of factors that may be responsible for menorrhagia.
A.Hormonal imbalance:The balance between two hormones; oestrogen and progesterone, regulates the build up of the lining of the uterus (endometrium), which is shed during menstruation. When there is a disturbance in these hormones, the endometrium develops in excess and eventually sheds heavy menstrual bleeding. Any woman at any time in her reproductive life may experience heavy menstrual bleeding. Young women who aren’t yet ovulating regularly are prone to menorrhagia especially 12 to 18 months after their first menstrual period (menarche).
Older women approaching menopause often experience hormonal imbalance that can cause menorrhagia. Women at higher risk also include those with hereditary bleeding disorders. Failure of the ovaries to ovulate properly may cause hormonal imbalance and result in menorrhagia. Sometimes, the imbalance can be caused by external factors such as thyroid diseases. While the heavy menstrual flow often can be controlled with hormone medications, however, improper use of hormonal medications can also be a direct cause of menorrhagia.
B. Uterine fibroids; theseare benign tumours of the womb which tend to appear during your childbearing years. Depending on their position within the womb, they may cause heavier than normal or prolonged menstrual bleeding. Similarly Polyps–small, benign growths on the lining of the uterine wall commonly occur in women of reproductive age as the result of high hormone levels- that may cause heavy or prolonged menstrual bleeding.
C. Adenomyosis is a condition where glands from the lining of the womb become embedded in the uterine muscle, often causing heavy bleeding and pain. Adenomyosis is most likely to develop if you’re a middle-aged woman who has had many children (Pregnancy complicationswhether due to miscarriage or ectopic pregnancy (pregnancy outside the womb can cause heavy bleeding as well)
D. Cancer whether in the womb or neck of womb or in the ovaries may cause excessive menstrual bleeding as well.
E. The use of Intrauterine device (IUD) may result inmenorrhagia, in that case you’ll need to remove it.
F. Medications including anti-inflammatory medications and anticoagulants (to prevent blood clots), can contribute to heavy or prolonged menstrual bleeding.
Management of menorrhagia
All sexually active women should have yearly pelvic exams and regular Pap tests between 1-3 years. However, if you experience heavy or irregular vaginal bleeding, schedule an appointment with your doctor and be certain to record when the bleeding occurs during the month. If you’re having heavy vaginal bleeding, soaking at least one pad or tampon an hour for more than a few hours or if you have severe menstrual pain that doesn’t respond to your usual pain killers, then you need to visit your doctor. As well as bleeding past the age of menopause should be regarded as serious.
What should you expect at the doctor?
You will be asked about your medical history and the pattern of your menstrual cycles. You may be asked to keep a diary of bleeding and non-bleeding 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 is evaluated in case excessive blood loss during menstruation has made you anaemic. Tests may also be done to check for thyroid disorders or blood-clotting abnormalities.
Pap test where your doctor collects cells from your womb’s neck for microscopic examination to detect infection, inflammation or changes that may be cancerous or may lead to cancer. Your doctor may also take an endometrial biopsy, which is a sample of tissue from your uterus to be examined under a microscope. Ultrasound scan will be performed to check your womb and both tubes and ovaries. This is done to exclude any pelvic pathology.
Further investigations may be ordered depending on the initial results;
Hysteroscopy, which is a small telescope, used to visualise the inside of the womb and neck of womb, this is done to exclude any pathology within your womb. The procedure can be done either with the patient awake or under general anaesthetic depending on the patients’ condition and desire. A biopsy will be taken from the lining of the womb and sent to the pathology lab for examination. 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.
If untreated, what problems can menorrhagia cause?
Excessive or prolonged menstrual bleeding can lead to other problems including; Iron deficiency anaemia, it is a common type of anaemia where the level of haemoglobin in blood is low, and this is a substance that enables red blood cells to carry oxygen to tissues. Menorrhagia may deplete iron levels enough to increase the risk of iron deficiency anaemia. Symptoms include; pallor, weakness and fatigue. Although diet plays a role in iron deficiency anaemia, the problem is complicated by heavy menstrual periods. Most cases of anaemia are mild, but even mild anaemia can cause weakness and fatigue. Moderate to severe anaemia can also cause shortness of breath, rapid heart rate, light-headedness and headaches.
Dysmenorrhea; is a heavy menstrual bleeding often accompanied by menstrual cramps. Sometimes, the cramps associated with menorrhagia are severe enough to require medication or surgical interventions.
Treatment of menorrhagia
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 and procedures or therapies. The likelihood that your periods will become less heavy before long, affects your lifestyle and most important your opinion or personal preference.
Iron supplements are prescribed if the condition is accompanied by anaemia. If your iron levels are low but you’re not yet anaemic, you may start taking iron supplements rather than waiting until you become anaemic.
Tranexamic acid is a drug used commonly to treat heavy periods, it is non-hormonal thus can be used during the time of bleeding and does not need to be used continuously through out the cycle like other hormones.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).
Oral contraceptives provide effective birth control and can help regulate ovulation and reduce episodes of excessive or prolonged menstrual bleeding. Progesterone only medications can help correct hormonal imbalance and reduce menorrhagia as well.
If you have menorrhagia resulting from hormonal medication, you and your doctor may be able to treat the condition by changing or stopping your medication.
Mirena coil is a medicated coil that is inserted into the womb similar to regular coils. But it is highly effective in reducing menstrual blood loss up to complete amenorrhea, where the periods may completely stop. It can be replaced every 5 years or removed if you wish to have more children. This type of coil is now available in Egypt.
You may need surgical treatment for menorrhagia if drug therapy is unsuccessful. Treatment options include:
Operative hysteroscopy, used to remove a polyp or a fibroid from your womb.
Endometrial ablation; using ultrasonic energy, your doctor permanently destroys the entire lining of your uterus (endometrium). After endometrial ablation, most women have normal menstrual flow. However, some women have little or no menstrual flow after that procedure.
Endometrial resection; this surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding but don’t have other underlying uterine problems such as large fibroids, polyps or cancer. Endometrial ablation and resection can be performed only for women who have completed their family and have no desire for any more children.
Hysterectomy; where the womb is removed resulting in sterility and cessation of menstrual periods. You’ll need anaesthesia and hospitalisation. Additional removal of the ovaries may cause premature menopause in younger women. Because hysterectomy is permanent, be sure you want this treatment before going ahead with surgery. Hysterectomy can be done through key-hole surgery, with 3 tiny holes in your tummy; you can go home within 24 hours from the procedure and resume full activity within few weeks. It does not leave a big scar behind and is less likely to cause adhesions or scar tissue inside your tummy. Except for hysterectomy, these surgical procedures are usually done on an outpatient basis. Although you may need a general anaesthetic, it’s likely that you can go home later on the same day.