What causes heavy menstrual bleeding?
It is one of the most common gynecologic complaints, and it affects over 10 million women in the United States annually.
What is menorrhagia
Average blood loss during menstruation is around 30 to 40 milliliters, or 2 to 3 tablespoons, over a period of 4 to 5 days. Officially, menorrhagia is a loss of over 80 milliliters of blood in one cycle, or twice the normal amount.
Menorrhagia may be accompanied by pain and discomfort.
In reality, when a woman approaches the doctor, it is normally the effect of the bleeding on daily life that is more significant.
An alternative definition that has been suggested is, "Menstrual loss that is greater than the woman feels she can reasonably manage."
This type of flow lasts longer than 7 days, and it requires a woman to change her pad or tampon every 2 hours or more.
She may also pass blood clots larger in size than a quarter, and she may experience anemia due to the volume of blood loss.
Menorrhagia is one of the most commonly reported gynecologic complaints. In half of the women diagnosed, an underlying cause cannot be identified, but it can be a sign of a serious problem.
Menorrhagia may happen when a menstrual cycle does not produce an egg, leading to a hormone imbalance. Menstrual cycles without ovulation, known as anovulation, are most common in those who:
- Have recently started menstruating
- Are approaching menopause
Other underlying reasons for menorrhagia may be:
Hormonal disturbances just before the menopause can lead to heavy bleeding.
- Hormonal disturbances: If there is a change in the normal fluctuations of progesterone and estrogen, the endometrium, or inner lining of the uterus, can build up too much. This is then shed during menstrual bleeding.
- Ovarian dysfunction: If the ovary does not release an egg, no progesterone is produced, resulting in a hormone imbalance.
- Uterine fibroids: These are noncancerous, or benign, tumors.
- Uterine polyps: These benign growths can result in higher hormone levels.
- Adenomyosis: Glands from the endometrium become embedded in the muscle of the uterus.
- Non-hormonal Intrauterine Device (IUD): This type of birth control device can lead to heavier bleeding than normal.
- Pelvic inflammatory disease (PID): This is an infection of the reproductive organs that can have severe complications.
- Pregnancy-related complications: Examples are a miscarriage or an ectopic pregnancy.
- Cancer: Uterine, cervical, and ovarian cancers affect the reproductive system.
- Inherited bleeding disorders: These include Von Willebrand's disease or a platelet function disorder.
- Medications: Anti-inflammatory and anticoagulant drugs can lead to heavy bleeding.
Other health conditions that can trigger menorrhagia include thyroid disorders, endometriosis, and liver or kidney disease.
Signs and symptoms of menorrhagia can include the following:
- Heavy vaginal bleeding, resulting in the saturation of one or more sanitary pads or tampons every hour for several hours
- Heavy bleeding requiring the use of double sanitary protection
- Having to change pads or tampons in the middle of the night
- Menstrual flow or bleeding lasting more than a week
- Passage of blood clots that are the size of a quarter or larger
- Inability to perform regular daily activities because of the bleeding
- Signs and symptoms of anemia, including tiredness, fatigue, and shortness of breath
- Constant lower abdominal and pelvic pain
If bleeding interferes with daily life and social, physical, or emotional wellbeing, it is appropriate to seek help.
Treatment of menorrhagia depends on the individual case.
Birth control pills can help to regulate hormones.
Drug therapy includes:
- Iron supplements to treat anemia
- Tranexamic acid, or Lysteda, taken at the time of bleeding to help reduce blood loss
- Oral contraceptives to regulate the menstrual cycle and decrease bleeding duration and quantity
- Oral progesterone to treat hormonal imbalance and reduce bleeding
- Hormonal IUD to thin the lining of the uterus, reducing bleeding and cramping
In women who have a bleeding disorder, such as von Willebrand's disease or mild hemophilia, Desmopressin nasal spray, or Stimate can boost the levels of blood-clotting proteins.
Nonsteroidal anti-inflammatories (NSAIDs), such as ibuprofen, or Advil, can be used to treat dysmenorrhea, or painful menstrual cramps, and they can help reduce blood loss. However, NSAIDS can also increase the risk of bleeding.
A number of surgical procedures are available to treat or relieve the symptoms of menorrhagia.
- Dilation and curettage (D&C) is a surgical procedure for scraping the lining of the uterus
- Uterine artery embolization treats fibroids, a cause of menorrhagia, by blocking the arteries that feed them
- Hysteroscopy involves inserting a camera into the uterus to evaluate the lining, assisting in the removal of fibroids, polyps, and the uterine lining.
- Focused ultrasound ablation uses ultrasonic waves to kill fibroid tissue.
- Myomectomy is a surgical intervention to remove uterine fibroids through several small abdominal incisions, an open abdominal incision, or through the vagina.
- Endometrial ablation permanently destroys the lining of the uterus.
- Endometrial resection uses an electrosurgical wire loop to remove the uterine lining.
- Hysterectomy removes the uterus and cervix, and, sometimes, the ovaries.
The choice of intervention will take into account the cause and extent of the condition, the age and health of the patient, and their personal preference and expectations.
A doctor will ask the patient about symptoms and will carry out a physical examination.
If bleeding makes daily activities difficult, it is a good idea to see a doctor.
Tests that can help to evaluate for menorrhagia include:
- Blood tests to check for disorders such as anemia, thyroid disease, and clotting disorders
- Pap smear to evaluate for cervical infection, inflammation, dysplasia, and cancer
- Endometrial biopsy to test the lining of the uterus for cellular abnormalities and cancer
- Ultrasound to evaluate the pelvic organs including the uterus, ovaries, and pelvis
- Sonohysterogram, which involves instilling fluid into the uterus and using ultrasound to evaluate the uterus for abnormalities
- Hysteroscopy, in which a camera is inserted into the uterus to inspect the lining
- Dilation and curettage, used as treatment but also to detect abnormalities
Keeping a diary of the length and heaviness of menstruation may help in diagnosis.
Other types of abnormal bleeding include:
- Polymenorrhea: Menstruation that happens too often
- Oligomenorrhea: Menstruation is too light or infrequent
- Metrorrhagia: Irregular bleeding that happens between cycles and does not appear to be linked to menstruation
- Postmenopausal bleeding: Occurs more than a year after the last normal period at the menopause
Anyone who is concerned about heavy bleeding or other types of abnormal bleeding should discuss their concerns with a doctor.