Menorrhagia

Every woman is different, which means the amount of blood lost during a menstrual period differs from person to person. A large loss of blood can affect women both physically and emotionally and can be a very distressing time.

If you bleed after you have been through menopause it is important to see your doctor for advice.

Heavy periods (or menorrhagia) may be hard to define, but if you feel you are using more tampons or sanitary towels than usual, or blood is leaking through to your clothes or bedding, this usually means your period is heavy. Heavy periods can also mean you need to change protection overnight, the need to change soaked protection every 1-2 hours, you are passing clots larger than a 50 cent piece, you bleed for more than 7 to 8 days or the heavy bleeding restricts your usual day to day activities.

Heavy bleeding is sometimes caused by problems with the lining of your uterus (endometrium) or a hormonal disorder. Sometimes it can be due to your medications, or a medical illness. But in half of all women with heavy bleeding, no cause is ever found.

You should visit your doctor if heavy periods are disrupting your everyday life. Your doctor may want to investigate the possible causes of heavy bleeding to rule out any other health conditions which may be causing it. There are effective treatment options available for heavy periods.

Blood is full of iron, which helps red blood cells carry oxygen around the body. Heavy blood loss month after month can lead to a loss of iron resulting in iron deficiency or, if the iron deficiency is prolonged or severe, anaemia (low haemoglobin).

Symptoms of iron deficiency or anaemia include tiredness, a lack of energy, shortness of breath, palpitations and headaches.

If you are concerned about this, you should visit your doctor.

Looking after yourself

Here is some self-care advice for coping with heavy periods:

• Make sure you change your tampon or sanitary towel at regular intervals. The recommended time frame is every 4 to 8 hours for a tampon, and every 4 to 5 hours for a sanitary towel.
• You can use a heat pack or pain relief medication if you are in pain.
• You may need to use more tampons or pads on the heavier days of your period. However, if you are changing your protection every 1 to 2 hours due to heavy blood loss, you should visit your doctor for advice
• Hygiene is very important when changing sanitary products. Always wash your hands before using a new tampon or sanitary pad, and always wash your hands well afterwards too.
• Sleeping. You can sleep with a tampon or sanitary pad in place, but it should be changed immediately before bedtime and first thing in the morning. 
• Drink plenty of clear fluid a day (water is best) unless you have an existing medical condition which means this is not possible.
• If you are in pain, get advice on medicines you can take.

Causes of heavy menstrual flow

In some cases, the cause of heavy menstrual bleeding is unknown, but several conditions may cause menorrhagia. Common causes include:

• Hormone imbalance. In a normal menstrual cycle, a balance between the hormones oestrogen and progesterone regulates the build-up of the lining of the uterus (endometrium), which is shed during menstruation. If a hormone imbalance occurs, the endometrium grows excessively and eventually sheds by way of heavy menstrual bleeding.
  
  A number of conditions can cause hormone imbalances, including polycystic ovary syndrome (PCOS), obesity, insulin resistance and thyroid problems.
   
• Hormonal dysfunction of the ovaries. If your ovaries don't release an egg (ovulate) during a menstrual cycle (anovulation), your body doesn't produce the hormone progesterone, as it would during a normal cycle. This leads to hormonal imbalance and may result in menorrhagia.
   
• Uterine fibroids. These common noncancerous (benign) growths of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.
   
• Polyps. Small, benign growths in the lining of the uterus (uterine polyps) may cause heavy or prolonged menstrual bleeding.
   
• Adenomyosis. This condition occurs when glands from the uterine lining (endometrium) start to grow in the uterine muscle (myometrium), often causing heavy bleeding and painful periods.
   
• Non Hormonal Intrauterine contraceptive device (Copper IUD). Menorrhagia is a well-known side effect of using a non-hormonal (copper) intrauterine device for birth control. Your doctor will help you plan for alternative management options.
   
• Pregnancy complications. A single, heavy, late period may be due to a miscarriage. If in doubt perform a home urine pregnancy test or see your doctor for advice.
   
• Cancer. Uterine cancer and cervical cancer can cause excessive menstrual bleeding, especially if you are postmenopausal or have had an abnormal Pap test in the past.
   
• Inherited bleeding disorders. Some bleeding disorders — such as von Willebrand's disease, a condition in which an important blood-clotting factor is deficient or impaired — can cause abnormal menstrual bleeding.
   
• Medications. Certain medications, including anti-inflammatory medications, hormonal medications such as oestrogen and progestogens, and anticoagulants such as Warfarin or Xarelto, can contribute to heavy or prolonged menstrual bleeding.
   
• Other medical conditions. A number of other medical conditions, including liver, kidney or thyroid disease may be associated with menorrhagia.

Testing and investigations

The doctors at Create Health can help you with advice and treatment options to control your menstrual flow. Your doctor will ask about your medical history and menstrual cycles. A physical examination is often needed. You may need one or more tests or procedures such as:

• Blood tests. A sample of your blood may be evaluated for iron deficiency (anemia) and other conditions, such as thyroid disorders or blood-clotting abnormalities.
   
• Cervical screen (PAP test). In this test, cells from your cervix are collected and tested for infection, inflammation or changes that may be precancerous possibly leading to future cervical cancer.
   
• Endometrial biopsy. Your doctor may take a sample of tissue from the inside of your uterus to be examined by a pathologist.
   
• Ultrasound. This imaging method uses sound waves to produce images of your uterus, ovaries and pelvis.

Based on the results of your initial tests, your doctor may recommend further testing, including

• Hysteroscopy and D and C. This exam involves in hospital under a light anaesthetic inserting a thin, lighted instrument through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus and to remove any uterine growths. A sample of the uterine lining is also taken for assessment with a small instrument called a curette (D & C).

Treatment options

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

Medical treatment options for heavy menstrual flow

Medical therapy for menorrhagia may include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen (Nurofen), mefenamic acid (Ponstan) or naproxen sodium (Naprosen), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).
   
• Tranexamic acid. Tranexamic acid (Cyclokapron) reduces menstrual blood loss by up to 50% and only needs to be taken during the heavy bleeding days.
   
• 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. The hormone progesterone can help correct hormone imbalance and reduce menorrhagia.
   
• Hormonal IUD (Mirena or Kyleena). These intrauterine devices release a type of progestin called levonorgestrel, which makes the uterine lining thin, significantly reducing menstrual blood flow (>90% reduction) 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.

If you also have anaemia due to menorrhagia, your doctor may recommend that you take iron supplements regularly or to have an iron infusion.

Surgical treatment options for heavy menstrual flow

You may need surgical treatment for menorrhagia if medical therapy is unsuccessful. Treatment options include:

• Hysteroscopic resection of uterine growths. This surgical procedure uses a hysteroscope (a small uterine camera telescope placed through the vagina into the uterus) with a small electrical wire attached to its end to remove uterine polyps or fibroids. 
   
• Endometrial ablation. This procedure involves sealing (ablating) the lining of your uterus (endometrium). The procedure uses a radiofrequency device or electrical heat applied to the endometrium to destroy the tissue. After endometrial ablation, most women have much lighter periods and at times no period at all. It is a permanent procedure but not contraceptive. It is imperative to avoid falling pregnant. The continuous use of reliable or permanent contraception until menopause is needed.
   
• Myomectomy. This procedure involves the surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may perform the myomectomy hysteroscopically through the vagina, through one or more small abdominal incisions (laparoscopically), or through an abdominal incision if the fibroids are very large. The doctors at Create Health specialise in minimally invasive surgery so usually can avoid open abdominal incisional surgery.
   
• Hysterectomy. Hysterectomy, surgery to remove your uterus and usually cervix, is a permanent procedure that allows you to never have a period again. Usually your ovaries are retained so it will not affect your natural hormonal balance and therefore will not cause you to go into early menopause. Hysterectomy is performed in hospital under usually a general anaesthetic. Hysterectomy can be performed laparoscopically, vaginally or occasionally through an abdominal incision. The doctors at Create Health specialise in minimally invasive surgery so usually can often avoid open abdominal incisional surgery.

The gynaecologists at Create Health are experienced in managing all aspects of heavy menstrual flow. We can discuss all the available treatment options with you. Please phone or email us for an appointment or for further information.