Menorrhagia - What is menorrhagia?

Article by Dr Christopher Ng

Menorrhagia - What is menorrhagia?

Dr Christopher Ng

Obstetrician & Gynaecologist
Imperial College, London, United Kingdom
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What is menorrhagia?

Normal menstrual flow occurs every 21 to 35 days, lasts three to seven days and the total blood loss is about 30 to 80 mls (2 to 5 1/2 tablespoons). Every woman’s menstrual cycle is different.  Some women may think that they have heavy periods but they may not be actually experiencing menorrhagia. Menorrhagia affects 9-14% of menstruating women and is defined as menstruation at the expected intervals but with duration lasting longer than 7 days or excessive flow with more than 80 mls (> 5 1/2 tablespoons) of blood loss during each menstrual cycle. Some useful signs and symptoms to know whether you have menorrhagia include:

§     Menstrual flow that includes large blood clots

§     Menstrual periods lasting longer than seven days

§     Hourly soaking up of one or more sanitary pads or tampons for several consecutive hours

§     The need to use double sanitary protection in order to control menstrual flow

§     The need to change sanitary protection during the night

§     Interference of regular lifestyle by heavy menstrual flow

§     Symptoms of anemia (tiredness, fatigue or shortness of breath) 

Who are prone to such disease?

The 3 most common causes of menorrhagia in Singaporean women are hormonal imbalances, fibroids, adenomyosis and dysfunctional uterine bleeding. There are many causes of heavy menstrual bleeding (menorrhagia) but sometimes the cause is unknown (dysfunctional uterine bleeding which is a diagnosis of exclusion). Common causes include:

  • Hormonal imbalance. A normal balance between the female hormones oestrogen and progesterone regulates the buildup of the lining of the uterus (endometrium) and its shedding during menstruation. In the presence of hormonal imbalances, the endometrium thickens excessively and eventually sheds as heavy menstrual bleeding.
  • Uterine fibroids. Uterine fibroids are benign (non-cancerous) overgrowths of fibrous and smooth muscle tissue of the uterus. They are very common in women of reproductive age and rarely cancerous (1%). Most women with fibroids are asymptomatic but some may experience menorrhagia especially if the fibroid is big or too numerous.
  • Adenomyosis. This condition occurs when the tissues that line the inside of the uterus (endometrium) are found in the uterine muscles. They cause the uterus to be enlarged resulting in heavy painful periods.
  • Polyps. These small benign growths that protrude from the lining of the uterus (uterine polyps) may cause heavy prolonged menstrual bleeding. They may be the result of high hormone levels and usually occur in women of reproductive age.
  • Dysfunctional ovaries. Lack of ovulation (anovulation) may cause hormonal imbalance and result in menorrhagia.
  • Cancer. Uterine, cervical and ovarian cancer can cause excessive menstrual bleeding. In the case of uterine and cervical cancer, the abnormal bleeding tends to present during the early stages of these cancers unlike ovarian cancers which occurs during more advanced stages.
  • Intrauterine contraceptive device (IUCD).  Non-hormonal intrauterine device for birth control can cause excessive menstrual bleeding especially during the first few weeks after insertion.
  • Medications. Certain drugs like anticoagulants (to prevent blood clots) can contribute to heavy prolonged menstrual bleeding.
  • Medical conditions.  Pelvic inflammatory disease (PID), thyroid disorders as well as liver or kidney disease, may cause menorrhagia.
  • Inherited bleeding disorders. Blood coagulation disorders can cause abnormal menstrual bleeding.​

What are some of the treatments for it?

This really depends on the underlying cause and severity of menorrhagia.  This can be treated with medication and sometimes surgery. Drug therapy for menorrhagia may include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs  not only reduce heavy menstrual blood loss but also relieve painful menstrual cramps (dysmenorrhea).
  • Antifibrinolytic. Antifibrinolytic works by increasing clot formation and therefore is useful in stopping severe heavy menses.
  • Oral contraceptives. They are able to reduce menstrual blood loss rapidly and effectively by up to 50% - 88%.
  • Oral progesterone. Cyclical progesterone consumed orally during each month or via injections every 3 monthly can help correct hormonal imbalance and reduce menorrhagia.
  • The hormonal Intra-Uterine System, IUS. This type of intrauterine device releases a progestin called levonorgestrel, which thins the uterine lining and decreases menstrual blood flow and cramping in addition to being an effective medium term reversible contraceptive.
  • Removal of IUCD and cessation of medications. Other alternative methods of contraception would have to be used if the IUCD is removed and dosage adjustment or alternative medication can be tried if the current medication is stopped.
  • Treating the medical condition. Proper treatment (thyroid disorders, coagulation problems) with the appropriate drugs will result in lighter periods.

These are considered first line treatments for menorrhagia. In cases of anaemia as a result of menorrhagia, iron supplements can be given too. 

Surgical treatment may be needed if medical treatments prove unsuccessful. Treatment options include:

  • Dilation and curettage (D & C). In this common procedure, the cervix is gently dilated and scrapings of endometrial tissues are taken to reduce menstrual bleeding and more importantly to exclude endometrial cancer.
  • Operative hysteroscopy. It involves placing a thin, telescope-like device through the vagina and cervix to look inside the womb so as to facilitate in the surgical removal of a polyp that may be causing excessive menstrual bleeding.
  • Endometrial ablation and resection. Endometrial ablation uses various techniques to permanently destroy the entire lining of your uterus (endometrium). In endometrial resection, the endometrium is removed with an electrosurgical wire.  After these procedures, most women have little or no menstrual flow and the ability to become pregnant in the future is reduced.
  • Myomectomy. This is the surgical removal of large fibroids that cause menorrhagia. The uterus is repaired so that fertility is preserved. There is a small risk of fibroid recurrence in this case.
  • Hysterectomy. This is the surgical removal of the uterus and cervix which is a permanent solution for the cessation of periods and results in sterility. 

Is there a chance of recurrence after treatment? How high is the chance?

The chance of recurrence will vary from patient to patient when a myomectomy is performed and this is a risk that patients have to be willing to take should they choose this treatment. The risk of recurrence is lower as the woman approaches menopause. There is no chance of recurrence with a hysterectomy.

How can women prevent it from happening?

Of all the possible causes of menorrhagia, very few are preventable. Ways to lessen the risk of having menorrhagia include:

  • Avoid using IUCD. Alternative means of contraception should be sought if this is found to be the cause of menorrhagia.
  • Stop or adjust the dosage of anticoagulation medication.
  • Medical conditions under control. When certain medical disorders (eg. hypothyroidism) are adequately treated, the risk of menorrhagia lessens.

Does menorrhagia lead to more serious disease? If yes, what is it?

In most cases, menorrhagia is usually not life threatening unless in severe cases when this can lead to anaemia which can then be life-threatening and require blood transfusion.

 

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