Heavy periods (Menorrhagia)

Women of child-bearing age experience bleeding from the uterus every month. This bleeding is commonly known as menstruation or periods. When this bleeding occurs for a prolonged period of time or when there is excessive bleeding, the condition is termed menorrhagia. The bleeding in some cases is so severe that the daily routine gets affected and you are not able to perform your regular chores. Due to this excessive menstrual bleeding, you may suffer from conditions like anaemia.

Menorrhagia is widespread among women between 30 to 50 years of age and affects one out of every five women in this age group. Overall, it affects one out of every 20 women.

Signs and symptoms that are seen in women suffering from menorrhagia are as follows:

• Menstrual bleeding that lasts for more than seven days.
• A need to change one or more pads or tampons every hour.
• A need to use double sanitary pads at a time.
• A need to change pads or tampons during the night, disturbing your sleep.
• Large blood clots are seen on the pad. (Read more: Blood clots during periods)
• Shortness of breath.
• Heavy bleeding that interferes with your normal daily chores.
• Pain in the lower abdomen.
• Tiredness due to lack of energy.

Menorrhagia should not be confused with the following conditions, which are also related to abnormal bleeding from the uterus but are different from menorrhagia:

• Metrorrhagia
  Irregular and non-menstrual bleeding that occurs in between the normal menstrual periods. Hence, it is also known as intermenstrual bleeding.
• Polymenorrhea
  Frequently occurring periods.
• Postmenopausal bleeding 
  Bleeding that is seen after at least six months of the previous normal menstruation at menopause.

Causes

In more than half of the women with menorrhagia, the underlying cause is unknown. A few  possible causes of menorrhagia can be classified into the following categories:

• Reproductive-system-related disorders
  • Fibroids and polyps 
    Non-cancerous masses of tissue in the uterus, like uterine fibroids and uterine polyps, may cause heavy and painful bleeding during menstruation.
  • Adenomyosis
    In adenomyosis, the tissue from the uterine lining (endometrium) gets embedded in the wall of the uterus (myometrium) causing painful and prolonged menses.
  • Endometriosis
    In endometriosis, the tissue of the lining of the uterus grows in other parts of the reproductive system, i.e., ovaries and fallopian tubes.
  • Polycystic ovary syndrome (PCOS)
    PCOS is a condition that causes irregular menses due to the presence of small fluid-filled cysts in the ovaries, but the heavy flow is experienced when menses begin again after a few months of gap.
  • Uterine or cervical cancer 
    In the case of cancer of the uterus, abnormal bleeding is observed, which usually occurs after menopause.
  • Pelvic inflammatory disease (PID)
    In PID, the upper genital tract, i.e., ovaries, fallopian tubes, and uterus, are infected causing pain in the abdomen, vaginal discharge, fever among other symptoms.
  • Pregnancy-related problems 
    A miscarriage or abortion can cause abnormal and heavy bleeding from the uterus.
• Other disorders
  • Bleeding-related disorders 
    These include platelet function disorder and deficiency of blood clotting factors. Platelets and clotting factors are an integral part of the blood-clotting mechanism, a dysfunction of which can cause heavy bleeding. (Read more: Blood clotting disorder)
  • Non-bleeding-related disorders
    These include the following:
    • Liver diseases
    • Kidney diseases
    • Thyroid diseases like underactive thyroid glands cause a reduced production of thyroid hormones leading to tiredness, weight gain, and feelings of depression. It also results in a decreased production of progesterone (that helps reducing blood flow) and increased production of oestrogen by the ovaries.
• Medical treatments
  • A birth-control device like an intrauterine device can cause heavy bleeding during the first three to six months of insertion. (Read more: Birth control methods)
  • Anti-coagulant drugs, which are taken to prevent clotting of blood also cause heavy menstrual bleeding.
  • Drugs used in chemotherapy sessions for cancer treatment.
  • Herbal drugs that cause changes in hormonal levels affecting your menses. These drugs include ginseng, soya, gingko, and others.

Risk Factors

The following are some of the established factors that increase the risk of heavy periods in women:

• Ageing has been found to be related to an increased incidence of menorrhagia.
• Women with a family history of heavy menstrual bleeding are more likely to develop this condition than those who do not.
• Obesity
• Emotional disturbances or stress.
• Diabetes
• Young women who have just started getting monthly periods may also show heavy bleeding.

It is not possible to prevent menorrhagia, but consulting your doctor can help you get the condition diagnosed and treated on time. It can also  prevent other health-related issues like anaemia that may occur due to menorrhagia.

Diagnosing menorrhagia is not as easy as it seems to be. This is because heavy bleeding could mean different things to different women. Your doctor will ask you the following questions to detect menorrhagia:

• Your age at first menses.
• Duration of your cycle.
• The number of days you bleed.
• The number of days when you heavily bleed.
• Life quality during the bleeding period.
• A family history of heavy flowing periods.
• Any psychological stress that you are facing.
• Weight-related problems.
• Any medicine you are currently taking.

The following investigations are then recommended to determine the cause of a heavy menstrual bleeding problem:

• Blood test
  A blood sample is collected using a needle and is tested for anaemia, thyroid hormone problem, or problem with the clotting time of the blood. (Read more: Bleeding/clotting time test)
• Endometrial biopsy 
  In a biopsy, a small sample of the tissue lining of the uterus (endometrium) is collected and tested for any abnormal cancerous or non-cancerous cells. Severe abdominal cramps might be experienced during this test.
• Ultrasound
  Ultrasound is an imaging technique used to observe the images of organs and tissues inside your body and determine if there is any abnormality.
• Pap test
  Pap test involves the collection of cells from your cervix by gently scraping it; cells are then tested for infection, inflammation, or abnormal cancerous growth.

Depending on the results of the above-listed tests, your doctor may recommend you more tests which are:

• Hysteroscopy 
  Hysteroscopy involves the use of a small camera fitted to a tube to view the inside of the uterus and check for the presence of fibroids, polyps, or other causes that may be the cause of bleeding.
• Sonohysterogram 
  A fluid is injected into the uterus via a tube through the vagina and cervix and the pelvis is then viewed using an ultrasonogram. This helps the doctor to determine problems in the endometrium, which is the innermost lining of the uterus.
• Dilation and curettage 
  A local or general anaesthesia will be administered before performing this test. The uterus lining is scraped and tested to find the cause of the heavy bleeding. This often acts as a therapeutic procedure too.

Treatment procedure for menorrhagia depends on the cause of bleeding and the severity of the condition. The following factors will be taken into consideration before beginning your therapy:

• Age
• Health status
• Medical history
• The response of your body to various medications and procedures
• Your wants and needs, e.g., if you don’t want to have periods or if you want to just reduce the bleeding among others.

The treatment plan includes medical and surgical treatments depending upon the need and condition of the woman. Drug therapy for heavy menstrual bleeding consists of the following:

• Iron supplements 
  Excessive bleeding can cause loss of iron and iron deficiency anaemia. Hence, iron supplements are given to increase the iron content in your body.
• Antifibrinolytic medicines 
  These drugs inhibit the breakdown of clots after their formation. Thus, they help in reducing the heavy blood flow.
• Non-steroidal anti-inflammatory drugs (NSAIDS) 
  Various painkillers like ibuprofen are given to reduce period pain, menstrual cramps, and bleeding. But in some cases, NSAIDs may cause an increase in bleeding. The risk vs benefits of NSAIDs will be analysed by your doctor before prescribing them.
• Oral contraceptives 
  Various birth control pills are prescribed to facilitate regular menses and reduce bleeding. These pills are generally a combination of oestrogen and progesterone that help reduce the heavy bleeding from the uterus. This can be preferred over intrauterine devices because they produce easily reversible contraception.
• Hormone therapy 
  Oestrogen or progesterone are given to women with a heavy flow to reduce bleeding.
• Desmopressin nasal spray 
  It increases the release of a clotting protein, which is present in the lining of the blood vessels and increases the clotting of the blood, thereby reducing prolonged bleeding. This is useful in women who suffer from certain bleeding disorders like von Willebrand disease or mild haemophilia.

The surgical treatment for menorrhagia includes the following:

• Intrauterine contraceptive devices 
  A drug-releasing intrauterine device is placed in the uterus that generally releases levonorgestrel hormone thereby reducing bleeding. It is the preferred treatment method by women, but it takes about six months to produce an effective result. It also acts as a contraceptive, but as soon as you stop using it, you can become pregnant.
• Hysterectomy 
  It is a major surgery that needs hospitalisation. In hysterectomy, the uterus is removed, and the woman will no longer be able to bear a child and have menses.
• Endometrial ablation
  Endometrial ablation destroys the innermost lining of the uterus using heat energy, cold, or laser and the woman will no longer be able to bear a child.
• Endometrial resection
  Endometrial resection is a procedure that removes the innermost lining of the uterus, and the women will be unable to conceive in future.
• Myomectomy
  Myomectomy is a surgical procedure to remove fibroids from the uterus without the removal of the uterus.
• Operative hysteroscopy 
  Operative hysteroscopy involves the use of a special tool that is used to view the uterus and can be helpful in removing fibroids, polyps, correcting abnormalities of the uterus, and removing the inner lining of the uterus to reduce the menstrual blood flow.
• Dilation and curettage
  Dilation and curettage involve the removal of the innermost layer of the uterus lining to decrease the blood flow. It may need to be repeated after a specific time interval.

Lifestyle management

The following are the simple management techniques that may help you if you are facing the problem of menorrhagia:

• You may stay home and rest when you are bleeding excessively and have severe cramps.
• Going out can be an option while menstruating heavily, only if there is not much discomfort and a washroom available to change pads at the place you are visiting.
• Always carry a sanitary pad or tampons in your purse while travelling.
• Try wearing dark coloured clothes that can help camouflage stains and you can move around freely without getting too conscious.
• Use a waterproof covering on your bed to avoid stains on your bed.

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Prognosis

Untreated menorrhagia can cause abdominal pain and other problems that can affect the quality of your life by interfering with your regular work. It can lead to anaemia and other health-related issues and make you feel tired. Timely diagnosis and intervention usually give excellent results.

Complications

The most commonly experienced complications of menorrhagia are:

• Anaemia 
  Iron deficiency anaemia is commonly observed in women with heavy periods due to loss of excess blood. The deficiency of iron leads to a reduction of haemoglobin content in the blood. Haemoglobin is an oxygen carrier, so, its deficiency will reduce the oxygen-carrying capacity of the blood. This further causes a reduction in the supply of oxygen to various tissues of your body leading to fatigue, weakness, and tiredness. If anaemia is left untreated, it may worsen and cause other health problems.
• Severe pain 
  It is a prevalent symptom of menorrhagia. Heavy menstruation may sometimes cause unbearable pain creating a need for pain-killer medications. The pain may also exceed the level where surgical intervention is needed.