Heavy periods (menorrhagia)

Summary

• Menorrhagia is excessive menstrual bleeding. Menorrhagia needs to be differentiated from metrorrhagia, which means bleeding from the womb, independent from the menstrual cycle.
• Menorrhagia is a common condition, which most women experience at some time in their lives.
• Many women experience heavy bleeding in the last two to three years before menopause or in the first few years after menstruation begins.
• Underlying medical problems or hormone imbalances may cause menorrhagia.
• Treatment usually depends on age, whether or not you want children, any underlying disorder, other medical conditions and seriousness of the bleeding.
• Annual gynaecological examinations and regular Pap smears are important to screen for some of the more serious causes of menorrhagia.

What is menorrhagia?

Menorrhagia is a common disorder in which women have an unusually heavy or prolonged menstrual flow, with blood loss exceeding 80ml per menstrual period. (Average blood loss during a normal period is 30 to 50ml.) It can also be defined as a deviation from an individual's typical menstrual pattern, quantified by an increase of two or more sanitary pads a day or lasting three or more days longer than usual.

Heavy bleeding is particularly common during the last two to three years before menopause or the first few years after menstruation begins.

Menstruation

Menstruation is a normal part of the female reproductive cycle. While an egg matures inside the ovary in a blister called the graafian follicle, the follicle produces the hormone oestrogen, which causes the endometrium (the lining inside the womb) to grow. After ovulation (release of the egg from the follicle), the follicle changes into the corpus luteum (blister filled with yellow fluid), producing the hormone progesterone, which prepares the endometrium for implantation of the egg after fertilisation. If the egg is not fertilised, no implantation will take place and the endometrium is shed. The resulting menstrual flow typically consists of a few tablespoonfuls of blood and tissue fragments. These events repeat approximately every 28 days until interrupted by pregnancy or ended by menopause.

The degree of discomfort caused by a period and the amount of menstrual flow, vary considerably among individuals. Also, your own period may occasionally be heavier or more painful than usual.

What causes menorrhagia?

Conditions that can cause menorrhagia include a large number of gynaecological disorders and some outside of the reproductive system. Menorrhagia may be caused by:

• Hormonal imbalance. If the normal balance between the hormones oestrogen and progesterone is disturbed, the ripening and shedding of the endometrium is disorganised which can lead to menorrhagia.
• Uterine fibroids (benign tumours of the uterus). Together, hormonal imbalances and fibroids account for about 80 percent of menorrhagia cases.
• Polyps (small growths on the cervical or uterine wall).
• Adenomyosis (endometrial tissue growing between the muscle fibres of the uterine wall and causing enlargement of the uterus).
• Inflammation or infection of the pelvic organs.
• Liver or kidney diseases. Liver disease can cause abnormal oestrogen metabolism, resulting in excessive uterine bleeding.
• Blood diseases. Platelet disorders (coagulation disorders) most commonly cause excessive bleeding. The most common platelet disorder is Von Willebrand's disease. Leukaemia is another blood disorder that may cause menorrhagia.
• Hormone producing ovarian cysts and solid tumours.
• Cervical, ovarian or uterine cancer
• Lupus (chronic inflammatory disease of the connective tissue that can affect several organs).
• Thyroid conditions. Both too little (hypothyroidism) and too much (hyperthyroidism) thyroid production can cause menorrhagia.
• Anaemia and iron deficiency.
• Chemotherapy, anticoagulants (blood-thinning drugs), steroid therapy.
• Intrauterine devices (IUDs) for contraception. If you have menorrhagia and use an IUD, consider replacing it with an alternative contraceptive method.
• Obesity. This may be associated with increased oestrogen levels.

Who gets menorrhagia?

Menorrhagia is a common condition. About 20 to 25 percent of women report suffering from it. One in 20 women aged 30-49 consults her doctor each year with menorrhagia.

Risk factors

The risk of menorrhagia is greater for women who:

• Are obese.
• Are receiving oestrogen administration, without progestin. (Progestins are drugs that have a progesterone-like effect on the uterus).
• Have not established a regular ovulation cycle.
• Are approaching menopause.

What are the symptoms and signs of menorrhagia?

• Excessive menstrual flow (which varies greatly between women). If your menstrual flow is soaking through enough sanitary towels or tampons to require changing them more than every hour or two, or your period lasts longer than seven days, you are probably experiencing menorrhagia. Large clots of blood may pass. (Occasional clots are a normal part of menstruation - they are part of the uterine lining being shed.)
• Paleness and fatigue (anaemia) due to excessive blood loss.
• Pain or having the feeling of heaviness in the pelvic region.

How is menorrhagia diagnosed?

A detailed history of your general health and periods should be taken to assess whether you have menorrhagia and to identify or rule out disorders which may be causing it. You will probably have a gynaecological examination (internal examination and palpation of the reproductive organs).

The main diagnostic procedures for menorrhagia include:

• Transvaginal ultrasound: produces a picture of the uterus. Ultrasound pelvic examination is the best non-invasive technique for assessing uterine contour, endometrial thickness, and also the ovaries. It increases accuracy of diagnosis and assists in treatment choice, although it can occasionally miss intrauterine lesions. This can be minimised by instilling saline into the uterus at the time of the vaginal scan. This is called Saline Infusion ultrasound and delineates the cavity of the uterus more clearly.
• Hysteroscopy: involves a direct look at the inside of the uterus, enabling targeted biopsy of abnormal endometrium. Hysteroscopy and endometrial sampling have low complication rates, usually do not require inpatient admission and general anaesthesia, and are as accurate and cost-effective as a D&C.
• Endometrial sampling (endometrial biopsy): like a D&C, a sample of uterine tissue is taken. Endometrial sampling involves the passage of a small instrument through the cervix to scrape or brush the endometrial surface. This technique may be considered especially appropriate for women at risk of endometrial growths.
• Dilatation and curettage (D&C): a surgical procedure whereby the cervix is dilated and a curette (narrow, spoon-like instrument) is passed into the uterus so that a small sample of uterine tissue can be removed and examined. It usually requires a general anaesthetic and a one-day hospital stay. It is not cost-effective for diagnosing endometrial cancers in women younger than 40 (who have low prevalence of serious uterine conditions). Potential benefits must be weighed up against risks of general anaesthesia and possible uterine perforation and cervical laceration. A significant proportion of endometrial lesions are not detected by D&C, and its usefulness as a diagnostic tool without simultaneous hysteroscopy has been questioned.

Tests to investigate possible conditions associated with menorrhagia may include:

• Pap (cervical) smear
• Blood tests
• Pregnancy test when appropriate
• Thyroid function tests
• Urine and stool tests for conditions of the gastrointestinal and urinary systems
• Tests to determine if you are ovulating or have any sexually transmitted diseases

Chemotherapy, anticoagulants, steroids, hormone therapies and IUDs may cause menorrhagia. Since there are few laboratory tests for these causes, inform your doctor about any medications you are taking.

How can menorrhagia be prevented?

• Have an annual gynaecological examination and a Pap smear when indicated.
• Maintain the normal weight for your height, which helps to prevent excess fat formation and oestrogen production. Overweight women tend to have abnormal menstrual periods, perhaps because of an increase in oestrogens due to peripheral conversion of oestrogen precursors in fatty tissue.

How is menorrhagia treated?

• Treating the medical or physical (as in the case of an IUD) cause provides relief from menorrhagia.
• Treatment usually depends on age, whether or not you want children, on any underlying disorder, other medical conditions, and seriousness of the bleeding.
• Until recent years, conventional treatment has usually been hysterectomy. Now new low-risk technologies are emerging that are equally effective.
• An underlying medical condition causing menorrhagia should be treated. Polyps are generally removed; fibroids may require surgery to remove the fibroid, or hysterectomy. Hysterectomy, hormonal manipulation and radiation are the usual treatment for endometrial cancer.
• If you are using an IUD, consider changing to another method of contraception.
• If investigations show a hormone imbalance and no underlying medical cause, there are several possible approaches to treatment:
• Watchful waiting (monitoring bleeding for a few months before treating it).
• Hormone therapy (with birth control pills, hormone-replacement therapy, or progesterone).
• Insertion of a Mirena (A progesterone-containing IUCD which suppresses the lining of the uterus and hence decreases bleeding)
• D&C (although this is no longer as popular as before other options became available).
• Endometrial ablation (destruction of endometrial tissue).
• Hysterectomy (removal of the uterus and sometimes the ovaries).

Medication

The primary approach to treatment for menorrhagia which does not appear to be related to another underlying organic cause is drug therapy. The choice of drugs is determined by a woman's age, contraception use, tolerance of side-effects, cost, and whether bleeding is acute or chronic.

Menorrhagia is often successfully treated with progesterone or a combination of progesterone and oestrogen, usually taken as an oral contraceptive. Combined oral contraceptives can potentially reduce bleeding by up to 60 percent. Low doses can be used in older women who do not have progestin-related complications.

Older women with illnesses such as hypertension or diabetes or who smoke are not good candidates for high-dose progestin therapy or the “pill”/oral contraceptive.

Side-effects of progestins include weight gain, nausea, bloating, headaches and depression. Advantages include almost 15 percent reduction in menstrual blood loss and up to 86 percent reduction when used in place of an IUD.

If hormones cannot be taken for some reason, other medications to control bleeding may be recommended. Drugs such as tranexamic acid (Cyklokapron) can be effective in reducing menorrhagia. Tranexamic acid has few side-effects and also alleviates menstrual pain.

Non-steroidal anti-inflammatory drugs (NSAIDs) such as mefenamic acid, ibuprofen and naproxen can also be used to treat certain cases of menorrhagia, as well as any accompanying pain and discomfort. Advantages of NSAIDs include short-term duration of use - they are taken only during menstruation, for an average of five days. Side-effects include minor digestive tract disturbances and headaches.

Short-term relief can be obtained from GnRH agonists and danazol. These drugs may not be appropriate for chronic therapy because of the potential for long-term side-effects, including risk of osteoporosis and coronary artery disease.

Women who experience menorrhagia on a regular basis may have anaemia and treatment with iron supplementation may be necessary.

Surgery

1. Dilatation and curettage (D&C) can be both diagnostic and therapeutic. It involves dilating the cervix and scraping out the uterus. It should not be used without hysteroscopy. D&C is only a temporary measure in patients with an endocrinological (hormonal) disease, and typically lasts one to two months.
2. A simpler surgical procedure, endometrial ablation, has emerged in recent years as an alternative to hysterectomy for a select group of women. The gynaecologist inserts instruments through the cervix into the uterus and destroys the endometrium by laser, or various balloon techniques which transfer heat, cold or microwaves to the uterine lining. This relatively minor surgery can be performed in about 30 minutes under local or general anaesthesia (although most women prefer general anaesthesia). Patients typically leave the hospital the same day of the operation. Endometrial ablation is quicker, less traumatic, has a lower incidence of complications and a shorter recovery period than hysterectomy. Ablation is a reasonable alternative to hysterectomy, and its is appropriate for many women. Suitable candidates need to have minor or no uterine abnormalities, experience bleeding that can't be controlled with hormone therapy, or don't want long-term drug therapy. Ablation is reproducible and hardly ever needs repeating. Up to 40% of women develop absence of periods (amenorrhoea) and the rest have a 90% reduction in bleeding. It fails in 5 – 8% of women and these women may need hysterectomies. It should not be done in women wanting further pregnancies and one of the partners should be sterilised, as it is not effective as a contraceptive method.
3. If fibroids are the cause of bleeding, removing them but not the uterus - a procedure called myomectomy - may stop menorrhagia. It is mostly used for menorrhagia in women wishing to retain the uterus. Some abdominal myomectomies may be replaced by laparoscopic procedures. Laparoscopic myomectomy involves a shorter hospital stay than abdominal myomectomy, with probable advantages of reduced pain, reduced risk of wound complications, earlier return to normal activity and reduced costs.
4. Hysterectomy may be considered in persistent and severe cases where fertility is not a priority. This treatment stops menstruation permanently and results in sterility, which may be advantageous to some women. It also eliminates the threat of cervical and uterine cancer. In the standard approach, the gynaecologist removes the uterus through an abdominal incision which can require three to seven days in hospital and four to six weeks of recovery. A newer method, laparoscopically assisted vaginal hysterectomy, allows removal of the uterus through the vagina in selected patients. Vaginal hysterectomy is associated with similar complication rates, but less post-operative pain, shorter hospital stay and faster recovery than abdominal hysterectomy. It is performed in women who have given birth to a number of children and who may have uterovaginal prolapse (descent of the uterus and vagina). Hysterectomy is the preferred treatment for an enlarged uterus, for severe endometriosis, a desire for certain cure and if there is an increased risk for uterine cancer as detected by D&C. Hormone replacement therapy after hysterectomy is simplified for menopausal symptoms because only oestrogens without progestins need to be prescribed.

When to see your doctor

Women who are not pregnant and who experience a single episode of heavy bleeding usually require no medical treatment - getting sufficient rest often reduces the amount of blood flow.

Consult your doctor if you experience unusual heavy bleeding for longer than 24 hours, if a period lasts more than seven days and/or if periods are less than 21 days apart (unless that's normal for you).

(Reviewed by Dr Alan Alperstein, University of Cape Town)