Menorrhagia is the medical term for menstrual periods with abnormally heavy or prolonged bleeding. Although heavy menstrual bleeding is a common concern among premenopausal women, most women don’t experience blood loss severe enough to be defined as menorrhagia.
With menorrhagia, every period you have causes enough blood loss and cramping that you can’t maintain your usual activities. If you have menstrual bleeding so heavy that you dread your period, talk with your doctor. There are many effective treatments for menorrhagia.
There are many possible causes of heavy menstrual bleeding. They include:
- Hormonal imbalance, particularly in estrogen and progesterone; this is most common in adolescents who recently began their periods and women who are getting close to menopause. Hormonal imbalance may also occur if there is a problem in the function of the ovaries.
- Fibroids or noncancerous tumors of the uterus; fibroids typically occur during childbearing years.
- Miscarriage or ectopic pregnancy — the implantation of a fertilized egg outside the uterus, such as in the fallopian tube
- Use of blood thinners
- Problems with a non-hormonal intrauterine device (IUD) used forbirth control
- Adenomyosis, a condition in which the glands from the lining of the uterus become imbedded in the muscular wall of the uterus; this is most likely to occur in middle-aged women who have had several children.
- Pelvic inflammatory disease (PID), an infection of the uterus, fallopian tubes, and other organs of the reproductive system
- Uterine, ovarian, and cervical cancer; these are rare but possible causes of heavy menstrual bleeding.
- Other medical conditions that can prevent normal blood clotting, including liver, kidney, or thyroid disease, and bleeding or platelet disorders
Knowledge of normal menstrual function is imperative in understanding the etiologies of menorrhagia. Four phases constitute the menstrual cycle, follicular, luteal, implantation, and menstrual.
In response to gonadotropin-releasing hormone (GnRH) from the hypothalamus, the pituitary gland synthesizes follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which induce the ovaries to produce estrogen and progesterone.
During the follicular phase, estrogen stimulation results in an increase in endometrial thickness. This also is known as the proliferative phase.
The luteal phase is intricately involved in the process of ovulation. During this phase, also known as the secretory phase, progesterone causes endometrial maturation.
If fertilization occurs, the implantation phase is maintained. Without fertilization, estrogen and progesterone withdrawal results in menstruation.
Etiologic causes are numerous and often unknown. Factors contributing to menorrhagia can be sorted into several categories, including organic, endocrinologic, anatomic, and iatrogenic.
If the bleeding workup does not provide any clues to the etiology of the menorrhagia, a patient often is given the diagnosis of dysfunctional uterine bleeding (DUB). Most cases of DUB are secondary to anovulation. Without ovulation, the corpus luteum fails to form, resulting in no progesterone secretion. Unopposed estrogen allows the endometrium to proliferate and thicken. The endometrium finally outgrows its blood supply and degenerates. The end result is asynchronous breakdown of the endometrial lining at different levels. This also is why anovulatory bleeding is heavier than normal menstrual flow.
Hemostasis of the endometrium is directly related to the functions of platelets and fibrin. Deficiencies in either of these components results in menorrhagia for patients with von Willebrand disease or thrombocytopenia. Thrombi are seen in the functional layers but are limited to the shedding surface of the tissue. These thrombi are known as “plugs” because blood can only partially flow past them. Fibrinolysis limits the fibrin deposits in the unshed layer. Following thrombin plug formation, vasoconstriction occurs and contributes to hemostasis.
Anatomic defects or growths within the uterus can alter either of the aforementioned pathways (endocrinologic/hemostatic), causing significant uterine bleeding. The clinical presentation is dependent on the location and size of the gynecologic lesion.
Organic diseases also contribute to menorrhagia in the female patient. For example, in patients with renal failure, gonadal resistance to hormones and hypothalamic-pituitary axis disturbances result in menstrual irregularities. Most women in this renal state are amenorrheic, but others also develop menorrhagia. If uremic coagulopathy ensues, it usually is due to platelet dysfunction and abnormal factor VIII function. The resulting prolonged bleeding time causes menorrhagia that can be very tenuous to treat.
Due to the overwhelming factors that can contribute to the dysfunction of either the endocrine or hematological pathways, in-depth knowledge of an existing organic disease is just as imperative as understanding the menstrual cycle itself.
The signs and symptoms of menorrhagia may include:
- Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
- Needing to use double sanitary protection to control your menstrual flow
- Needing to wake up to change sanitary protection during the night
- Bleeding for longer than a week
- Passing blood clots with menstrual flow for more than one day
- Restricting daily activities due to heavy menstrual flow
- Symptoms of anemia, such as tiredness, fatigue or shortness of breath
One-third of all women experience heavy menstrual bleeding at some point in their life. In western countries, about 5% of women of reproductive age will seek help for menorrhagia annually. Half of all women who consult for hypermenorrhea have some uterine abnormality, most often fibroids (among patients under 40 years of age) and endometrial polyps (above 40 years of age). Appropriate treatment considerably improves the quality of life of these patients, and it is important to make a rigorous assessment of the patient to provide the best treatment options. This guideline provides instructions on how to examine and treat women of fertile age who have menorrhagia. The subject’s own assessment of the amount of menstrual blood loss does not generally reflect the true amount. All patients should undergo a pelvic examination and, if the menstrual pattern has changed substantially or if anaemia is present, a vaginal sonography should be carried out as the most important supplemental examination. Vaginal sonography combined with an endometrial biopsy is a reliable method for diagnosing endometrial hyperplasia or carcinoma, but it is insufficient for diagnosing endometrial polyps and fibroids; these can be diagnosed more reliably by sonohysterography or hysteroscopy. Non-steroidal anti-inflammatory drugs and tranexamic acid reduce menstrual blood loss by 20-60%, and the effectiveness of a hormonal intrauterine system (IUS) is comparable with that of endometrial ablation or hysterectomy. Cyclic progestogens do not significantly reduce menstrual bleeding of women who ovulate. Treatment should be started with one of the drug therapies, i.e. the IUS, tranexamic acid, anti-inflammatory drugs, or oral contraceptive. Drug treatment should be used and evaluated before surgical interventions are considered. With an effective training and feedback system, it is possible to organise the diagnostics, medical treatment and follow-up of heavy menstrual bleeding in the primary health care setting or in outpatient clinics, which reduces the burden on specialist health care.
Specific treatment for menorrhagia is based on a number of factors, including:
- Your overall health and medical history
- The cause and severity of the condition
- Your tolerance for specific medications, procedures or therapies
- The likelihood that your periods will become less heavy soon
- Your future childbearing plans
- Effects of the condition on your lifestyle
- Your opinion or personal preference
Drug therapy for menorrhagia may include:
- Iron supplements. If you also have anemia, your doctor may recommend that you take iron supplements regularly. If your iron levels are low but you’re not yet anemic, you may be started on iron supplements rather than waiting until you become anemic.
- Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).
- Tranexamic acid. Tranexamic acid (Lysteda) helps reduce menstrual blood loss and only needs to be taken at the time of the bleeding.
- Oral contraceptives. Aside from providing birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding.
- Oral progesterone. When taken for 10 or more days of each menstrual cycle, the hormone progesterone can help correct hormone imbalance and reduce menorrhagia.
- The hormonal IUD (Mirena). This intrauterine device releases a type of progestin called levonorgestrel, which makes the uterine lining thin and decreases menstrual blood flow and cramping.
If you have menorrhagia from taking hormone medication, you and your doctor may be able to treat the condition by changing or stopping your medication.
You may need surgical treatment for menorrhagia if drug therapy is unsuccessful. Treatment options include:
- Dilation and curettage (D&C). In this procedure, your doctor opens (dilates) your cervix and then scrapes or suctions tissue from the lining of your uterus to reduce menstrual bleeding. Although this procedure is common and often treats acute or active bleeding successfully, you may need additional D&C procedures if menorrhagia recurs.
- Uterine artery embolization. For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply.
During uterine artery embolization, the surgeon passes a catheter through the large artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with microspheres made of plastic.
- Focused ultrasound ablation. Similar to uterine artery embolization, focused ultrasound ablation treats bleeding caused by fibroids by shrinking the fibroids. This procedure uses ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure.
- Myomectomy. This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
- Endometrial ablation. Using a variety of techniques, your doctor permanently destroys the lining of your uterus (endometrium). After endometrial ablation, most women have much lighter periods. Pregnancy after endometrial ablation can put your health at risk — if you have an endometrial ablation, you should use reliable or permanent contraception until menopause.
- Endometrial resection. This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding. Pregnancy isn’t recommended after this procedure.
- Hysterectomy. Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. Hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.
Except for hysterectomy, these surgical procedures are usually done on an outpatient basis. Although you may need a general anesthetic, it’s likely that you can go home later on the same day.
When menorrhagia is a sign of another condition, such as thyroid disease, treating that condition usually results in lighter periods.