Definition of menorrhagia
Menorrhagia is the most common type of abnormal uterine bleeding. It is characterized by excessive and prolonged bleeding.
The amount of blood lost during a period varies from woman to woman, so it is difficult to define exactly what a heavy period is. But most women generally know how much blood loss is normal during the menses and when this amount is excessive. For instance, when having to use an unusually high number of sanitary tampons or towels, or when blood flows through the clothes or bedding, these are indications of excessive blood loss during the menses. Or more precisely: on the average in a normal menstrual cycle, the blood loss is about 2 to 3 tablespoons (30-40 ml) with bleeding lasting for five days but can occur up to 8 days, and it is considered that 5-6 tablespoons (about 80 ml) or more of blood loss may be indicative of menorrhagia. Most of the blood loss (90%) generally occurs in the first 3 days in either normal or heavy periods.
Heavy menstrual bleeding does not necessarily mean that anything is seriously wrong, but in some cases it can be so severe and relentless that it disrupts daily activities.
Other types of abnormal uterine bleeding include:
- Metrorrhagia: irregular non-menstrual bleeding between the menstrual periods
- Polymenorrhoea: too frequent menstrual periods
- Postmenopausal bleeding: bleeding occurring more than 6 months after the last normal menstrual period at menopause.
Frequency of menorrhagia
Menorrhagia is a common complaint:
- 1 woman out of 3 describes her periods as heavy
- 1 woman out of 20 aged 30 to 49 years consults her doctor each year for heavy periods and menstrual disorders
- It is the second commonest gynaecological condition to be referred to hospital, accounting for 12% of all gynaecological referrals.
Symptoms of menorrhagia
The signs and symptoms of menorrhagia may be as follows:
- Menstrual blood soaking through one or more sanitary tampons or pads every hour for several consecutive hours
- Need to use both pads and tampons to absorb the menstrual flow
- Need to change sanitary protection during the night
- Menstrual periods lasting more than seven days
- Large blood clots in the menstrual flow
- Pain and/or cramps in the lower abdomen during menstrual periods
- Tiredness, shortness of breath and faintness accompanying anaemia due to iron deficiency.
Diagnosis of menorrhagia
If the menstrual periods are felt as unusually heavy and disrupt the quality of life, it is recommended to see a doctor. After questioning about the current general health, medical history and occurrence of the above-described symptoms, the doctor will carry out a physical examination to check for polyps or womb enlargement. He/she may recommend one or more tests or procedures such as:
- Blood tests: a blood sample will be taken to check for an anaemic condition caused by the excessive bleeding, a thyroid disorder, a blood-clotting anomaly or the menopause
- Pap test: a sample of cells collected from the cervix will be examined under a microscope to detect infection, inflammation or changes that may be cancerous or lead to cancer
- Endometrial sampling (biopsy): a small sample of tissue from the inside of the uterus is collected for examination under a microscope to check for the presence of abnormal cells
- Ultrasound scan: this method produces images of the uterus, ovaries and pelvis and can usually detect fibroids (non-cancerous growths), polyps (harmless growths) and other changes in the structure of the womb.
Depending on the results of the above tests, further testing may be performed, including:
- Sonohysterogram: after injection of fluid into the uterus trough a tube via the vagina and the cervix, this ultrasound scan allows to detect problems in the lining of the uterus such as fibroids or polyps inside the womb and some forms of cancer
- Hysteroscopy: a tiny tube with a light is inserted into the uterus through the vagina and cervix to see the inside of the uterus
- Dilatation and curettage: the cervix is widened and a spoon-shaped instrument called a curet is inserted into the uterus to scrape a sample of tissue from the uterine lining which will be examined in the laboratory. This procedure is done under anaesthesia and is much less used nowadays as the above tests are usually sufficient.
Causes of menorrhagia
- Intrauterine devices for birth control
- Hormonal imbalance in oestrogen and progesterone levels. These two hormones regulate the build-up of the lining of the uterus which is shed during menstruation. In case of imbalance, the lining develops in excess and can be shed as heavy menstrual bleeding. Such imbalance occurs especially in adolescents experiencing their first menstrual periods and in women approaching menopause
- Dysfunction of the ovaries such as lack of ovulation. It may cause hormonal imbalance and consequently heavy periods
- High levels of prostaglandins (chemical substances that help to control muscle contractions in the uterus). They may affect blood clotting within the uterus
- High levels of endothelins (chemical substances that help the blood vessels to dilate). They may contribute to excessive bleeding
- Endometriosis. It occurs when the womb lining attaches itself to the pelvis, stomach or other organs in the body
- Pelvic inflammatory disease. It is an ongoing infection of the pelvis
- Uterine fibroids (non-cancerous growths in the muscles of the uterus). They may sometimes cause heavy or longer periods
- Abnormal pregnancy (ectopic, miscarriage)
- Infections, tumours or polyps in the cervix or womb cavity
- Bleeding or blood platelet disorders
- Liver, kidney or thyroid disease
- Polycystic ovarian disease
- Adrenal disorders and hyperprolactinaemia (raised blood levels of the hormone prolactin)
- Cancer of the uterus, ovaries or cervix. It is an uncommon cause, occurring in a small number of women, usually aged 40 or more
- Tuberculosis of the womb lining
- Chemotherapy for treating cancer
- Some medicines (such as anticoagulant or some non-steroidal anti-inflammatory drugs). They may interfere with blood clotting
- Obese women. They are more likely to have heavy periods than women of average weight.
Complications of menorrhagia
Iron-deficiency anaemia occurs in more than 50% of women with excessive bleeding. The blood is low on haemoglobin, a substance that enables red blood cells to carry oxygen to tissues. Low haemoglobin may result from insufficient iron as menorrhagia depletes iron levels, accompanied by signs and symptoms of pallor, weakness and fatigue, and in severe cases by shortness of breath, rapid heart rate, light-headedness and headaches.
Management of menorrhagia
Keeping a menstrual diary for a few periods may be a good option to assess before and after any treatment the amount of menstrual bleeding. This means to record during each period how many sanitary tampons or pads are needed each day and the number of days of bleeding. The occurrence of any flooding, symptoms or interruption of normal activities is also to be recorded. Such diaries can be obtained from the doctor or be “home made”. They are useful for both the patient and the doctor to assess the severity of the symptoms and whether a treatment is needed, as well as to check, if a treatment is started, whether it is efficient.
Conservative treatment
- General measures
- Get a rest if the bleeding is excessive and disrupts the normal daily activities
- Avoid medications interfering with blood clotting (anticoagulant and some non-steroidal anti-inflammatory drugs).
- Therapeutic measures
- Oral treatments
- Anti-haemorrhagic or haemostatic drugs of synthetic origin reduce the volume and duration of excessive menstrual blood loss by acting on the first step of haemostasis, and by improving platelet adhesiveness and restoring capillary resistance, but without interfering with blood clotting
- Non-steroidal anti-inflammatory drugs help to reduce menstrual blood loss and relieve painful cramps by lowering the body’s production of the hormone-like agent prostaglandin that causes excessive bleeding, but as some may interfere with blood clotting, only those prescribed by the doctor should be taken
- Anti-fibrinolytic agents reduce bleeding by preventing fibrinolysis and thus the breakdown of blood clots in the lining of the uterus
- Contraceptives prevent ovulation and reduce excessive or prolonged menstrual bleeding
- Progesterone helps to correct hormonal imbalance and reduce excessive menstrual bleeding by preventing the lining of the uterus from growing quickly
- If the condition is accompanied by anaemia, iron supplements are recommended
- Local treatments
- Levonorgestrel-releasing intrauterine device: a small plastic device is placed in the womb and slowly releases the hormone progestogen. It prevents the lining of the uterus from growing quickly and is also a contraceptive
- Injected or implanted treatments
- Progestogen: this hormone-like agent given as an injection or an implant prevents the lining of the uterus from growing quickly and is also a contraceptive
- Gonadotrophin-releasing hormone analogue: it is injected to prevent the body from producing the hormones oestrogen and progesterone and thus prevent the menstrual cycle to occur.
Interventional treatment
- Dilatation and curettage: the cervix is widened and a spoon-shaped instrument called a curet is inserted into the uterus to scrape tissue from the lining of the uterus to reduce menstrual bleeding.
- Operative hysteroscopy: a tiny tube with a light is inserted into the uterus through the vagina and cervix to see the inside of the uterus and can aid to remove the polyps responsible for excessive menstrual bleeding
- Endometrial ablation: most of the lining (endometrium) of the uterus is destroyed by ultrasonic energy. It reduces the ability to become pregnant
- Endometrial resection: an electrosurgical wire loop is used to remove the lining (endometrium) of the uterus. It reduces the ability to become pregnant
- Hysterectomy: the uterus and cervix are removed permanently by surgery. No pregnancies are possible after this procedure.
Any medical information on this website is not intended as a substitute for informed medical advice. No action should be taken before consulting with a healthcare professional.
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