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Heavy menstrual bleeding

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Overview

Heavy menstrual bleeding, formerly known as menorrhagia, is a common issue among women, though not all cases of heavy bleeding are severe enough to be classified as such. It’s considered heavy if it extends beyond seven days or involves losing more blood than usual during a menstrual cycle. This might involve needing to change your sanitary products every hour for several consecutive hours, or passing large blood clots, sometimes as big as a quarter or larger.

Additionally, some women experience bleeding between periods, or their menstrual bleeding may occur earlier or later than expected, which is referred to as abnormal uterine bleeding or irregular menstrual bleeding.

Heavy menstrual bleeding can significantly impact daily activities due to the intense flow and cramping. If your period is a source of dread due to these symptoms, it’s important to consult a doctor. There are various treatments available that can provide relief.

Symptoms

Heavy menstrual bleeding symptoms include:

  • Period lasting longer than 7 days
  • Passing blood clots that are at least 25 mm in size. The blood can seem rust-colored, pink, brown, or red
  • Using one or more tampons or sanitary pads every hour for a few hours straight
  • Requiring two sanitary pads in order to regulate the menstrual flow
  • Symptoms of anemia include fatigue, exhaustion, and shortness of breath
  • Waking late at night to replace tampons or sanitary pads
  • Losing over 80 milliliters of blood instead of the usual 35–40 milliliters during the menstrual cycle
  • Symptoms of pica disorder, such as pale skin, hair loss, and an inclination to eat anything other than food—such as paper, hair, or dirt

Women who encounter exceptionally heavy vaginal bleeding, saturating at least one pad or tampon per hour for more than two consecutive hours, bleeding between periods, or irregular vaginal bleeding, should promptly seek guidance from a healthcare provider. Any vaginal bleeding post-menopause necessitates immediate medical attention. These indicators may suggest underlying health issues that demand assessment and suitable medical intervention.

Causes

In some instances, the exact cause of heavy menstrual bleeding remains unidentified. However, several conditions can lead to this issue, including:

  • Hormonal imbalance:  In a typical menstrual cycle, the hormones estrogen and progesterone regulate the buildup of the uterus’s lining, known as the endometrium, which is shed during menstruation. However, when hormonal imbalances occur, the endometrium can thicken excessively, leading to heavy menstrual bleeding or unexpected bleeding between periods. Several conditions can disrupt hormonal balance, including obesity, insulin resistance, thyroid issues, and polycystic ovary syndrome (PCOS).
  • Issues related to the ovaries: An imbalance in hormones can lead to heavy menstrual bleeding or unexpected bleeding between periods. This occurs when the body fails to produce the hormone progesterone as it normally does during a menstrual cycle. This is often a result of a condition known as anovulation, in which an egg is not released by the ovaries during a menstrual cycle.
  • Uterine fibroids: Prolonged or more intense bleeding during menstruation might be caused by uterine fibroids.  These tumors appear in women who are fertile. Since they are benign, cancer is not present in them.
  • Polyps: These growths, often not malignant, may be responsible for bleeding between periods and can lead to spotting or bleeding after menopause. These tiny growths on the uterine lining can result in prolonged or heavy menstrual bleeding.
  • Adenomyosis: This condition can lead to painful periods, heavy or prolonged menstrual bleeding with clots, and abdominal/pelvic pain. Adenomyosis occurs when tissue similar to the uterus lining grows into the muscle wall, making the uterus thick and larger than usual, sometimes doubling, or tripling in size.
  • Intrauterine device (IUD): Progestin-containing IUDs may lessen heavy menstrual bleeding. One well-known negative effect of using a hormone-free IUD for birth control is heavy menstrual bleeding.
  • Pregnancy problems: Heavy bleeding in pregnancy can be caused by the placenta being in an unusual position, such as covering the uterus opening, a condition known as placenta previa. In some cases, a significant and delayed period might signal a miscarriage.
  • Cancer: Cervical cancer risk is increased in women with a history of abnormal Pap tests. Unexpected or severe menstrual flow, as well as abnormal uterine bleeding, might be symptoms of cervical or uterine cancer. Both before and after menopause, these tumors can occur.
  • Family history of bleeding disorders: Conditions such as von Willebrand’s disease, a disorder that causes improper blood clotting can lead to heavy menstrual bleeding.
  • Medications: Blood clot prevention medications like warfarin, enoxaparin, apixaban, and rivaroxaban can contribute to heavy menstrual bleeding. Hormonal medications like birth control pills containing estrogen and progestin, which usually reduce menstrual bleeding, may occasionally lead to unexpected bleeding between periods.
  • Other medical issues: Liver, kidney, and thyroid disease are among the various medical conditions that may cause heavy menstrual bleeding.

Risk factors

The release of an egg triggers the body to produce progesterone, a hormone crucial for maintaining regular menstrual cycles. Insufficient progesterone due to the absence of egg release can lead to heavy or unexpected bleeding between periods.
Several risk factors may contribute to heavy menstrual bleeding, such as:

  • Age: In adolescents, irregular or heavy menstrual bleeding commonly occurs when an egg is not released during a monthly cycle, especially within the first year after their first period.
  • Medical conditions: Various other factors, including uterine cancer, bleeding disorders, medication side effects, and liver or kidney disease, can cause significant menstrual bleeding. For older women in their reproductive years, issues with the uterus, such as fibroids, polyps, and adenomyosis, often contribute to heavy menstrual bleeding.

Diagnosis

The diagnosis of heavy menstrual bleeding usually involves a physical examination, a pelvic exam, inquiring about one’s medical history and menstrual cycles, possibly suggesting the maintenance of a diary to monitor bleeding patterns, flow intensity, and sanitary product usage.

The diagnosis of heavy menstrual bleeding or abnormal uterine bleeding is typically established only after ruling out other potential causes, including menstrual disorders, medical conditions, or medication-related factors.

Depending on the age and the severity of the symptoms, tests that may be required include:

  • Blood tests: Tests for illnesses like blood clotting issues or thyroid issues may be necessary. Blood test may also involve test for iron deficiency anemia.
  • Pap test: For women aged 25 and older, the cells are tested for the presence of the human papillomavirus (HPV). This examination involves gathering cells from the cervix, which are then analyzed for signs of inflammation or potential precancerous changes that might progress to cancer. (
  • Endometrial biopsy: This test look for indications of uterine cancer or precancerous growths. A tissue sample from the interior of the uterus is taken for laboratory analysis.
  • Imaging tests: Medical imaging techniques, such as magnetic resonance imaging (MRI) and ultrasound, are employed to see the structures inside the body. Ultrasound utilizes sound waves to generate images of the uterus, ovaries, and pelvis.

MRI is used to examine the interior of the uterus when ultrasound results are insufficient in providing detailed information about potential abnormalities. MRI is particularly useful in assessing structures within the uterus.

Additional tests that may be required depending on the initial results include:

  • Sonohysterography: This test, also known as saline-infusion sonography, is conducted to investigate issues within the uterine lining. Compared to a regular ultrasound, a sonohysterogram provides greater precision and sensitivity in identifying abnormalities within the uterine cavity. This procedure involves filling the uterus with saline to enable the healthcare provider to visualize its interior. The saline is injected via a tube into the uterus through the cervix and vagina.
  • Hysteroscopy: A hysteroscopy is performed to examine the presence of polyps, fibroids, or any irregular tissue in the uterus. Through the cervix and vagina, a small, lit device is placed into the uterus to visually inspect the vagina, cervix, and uterus. If any growths are identified as potential causes of bleeding, they can be removed during the hysteroscopy.

Treatment

The approach to treating heavy menstrual bleeding is contingent upon various factors including the root cause, severity, overall health, age, and medical history of the individual. Additionally, it takes into account the individual’s response to particular medications and personal preferences. For example, treatment may target either complete cessation of periods or reduction of bleeding, depending on the individual’s choice. Moreover, treatment decisions are influenced by the individual’s plans regarding pregnancy.

Treatment options include:

  • Medications: Individuals experiencing anemia resulting from excessive bleeding may receive prescriptions for iron supplements. Additionally, even in cases where iron levels are low without anemia, initiating iron supplements might be advised rather than waiting for anemia to develop. If heavy menstrual bleeding arises due to hormone medication, discontinuation or switching to an alternative medication may be necessary.

Medications that may be prescribed to treat heavy menstrual bleeding include:

    • Nonsteroidal anti-inflammatory drugs (NSAIDs):  These medications are effective in can providing relief from menstrual cramps and decrease bleeding. NSAIDs include ibuprofen or naproxen sodium.
    • Tranexamic acid: Antifibrinolytic medications, such as tranexamic acid, work by inhibiting the breakdown of clots, thus preventing excessive bleeding. One only need to take this medication when once they start bleeding.
    • Hormonal IUD: This thins the lining of the uterus and lessens discomfort and monthly blood flow. Levonorgestrel, a form of progestin released by IUDs
    • Oral contraceptives: These can help control irregular menstrual cycles and relieve heavy or extended menstrual bleeding.
    • Oral progesterone: The hormone progesterone, whether natural or in its synthetic form called progestin, can address hormone imbalances, and alleviate heavy menstrual bleeding.
    • Other medications: Gonadotropin-releasing hormone (GnRH) agonists are capable of temporarily halting or diminishing bleeding by inhibiting ovulation. On the other hand, GnRH antagonists, such as elagolix, are effective in managing heavy menstrual bleeding associated with fibroids. Additionally, desmopressin nasal spray can arrest bleeding linked to von Willebrand disease by aiding in blood clotting.
  • Procedures: Medication is typically the initial treatment option, followed by minor surgeries and surgical interventions. Many surgical procedures aimed at addressing heavy menstrual bleeding are often performed on an outpatient basis, enabling patients to return home the same day. While certain surgeries such as abdominal myomectomy or hysterectomy may require a short hospital stay, many are carried out under general anesthesia.

Surgical options include:

  • Dilation and curettage (D&C): This may be performed to identify the cause of abnormal uterine bleeding, such as polyps, fibroids, or uterine cancer. If one experienced a miscarriage, a D&C may be necessary to completely empty the uterus. In this procedure, the healthcare provider opens the cervix, known as dilating it, and then scrapes or suctions tissue from the uterine lining, called curettage. Hysteroscopy is often combined with D&C to help locate the source of bleeding in the uterus.
  • Hysterectomy: This is frequently employed for both the diagnosis and treatment of heavy menstrual bleeding. In an operative hysteroscopy, a slender, illuminated tube is inserted into the vagina, facilitating an examination of the uterine cavity. The hysteroscope serves as a precise surgical tool, enabling the removal of any growths that might be contributing to the bleeding.
  • Uterine artery embolization: During this procedure, a catheter is inserted into the major artery in the thigh. In order to stop the blood supply to the fibroid, tiny beads or sponges is inserted using a catheter that is guided to the uterine blood arteries. The purpose of uterine artery embolization is to obstruct blood flow to uterine fibroids. Reduced blood supply to fibroids aids in their shrinkage.
  • Focused ultrasound: This method, which does not require any incisions, reduces the size of fibroids by using ultrasound waves and radiofrequency energy to target and destroy them.
  • Myomectomy: This involves surgically removing uterine fibroids using different approaches. With hysteroscopic approach, a thin, flexible tube is inserted into the vagina and cervix to visualize and remove fibroids or polyps inside the uterus. With laparoscopic approach, several small incisions in the abdomen is done.
  • Endometrial ablation: Following endometrial ablation, periods are often significantly lighter. While pregnancy is unlikely, it is still possible and can be risky. It is advisable to use reliable or permanent birth control until menopause. Generally, endometrial ablation entails destroying the uterus lining, a process known as ablation, using methods like a laser, radio waves, or heat.
  • Endometrial resection: Pregnancy is not advised following this procedure. This usually employs an electrosurgical wire loop to eliminate the uterine lining.

In specific instances where excessive menstrual bleeding may signal an underlying condition, such as thyroid disease, addressing the root cause could result in a decrease in menstrual flow.

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Diseases & Conditions Heavy menstrual bleeding