What is the prevalence of heavy periods?
Menorrhagia - heavy periods (Greek: Meno - uterus; rhegnunai - to burst forth), the medical term for heavy periods, is a common problem.
Long heavy periods exacerbate the problem. Furthermore, the menstrual flow
with periods may not only
be long and heavy but also painful. Long, heavy and painful periods affect
many women. It has been estimated that one woman in 20 aged 25- 44 years will attend her general practitioner each year requesting treatment for her heavy periods. No doubt many more suffer in silence as, during a heavy period, most women understandably feel that they could not see a doctor because they would not wish to be examined. After a heavy period they will defer attending the doctor hoping that future periods will be normal.
Heavy periods can be debilitating, causing more than the usual inconvenience of menstruation. At times they can lead to social embarrassment. Modern women have the benefits of effective contraception, which has only been available for a generation or two. With a reduction in family size and less breast feeding, a woman can now expect to see a nine-fold increase in the number of menstrual cycles in her lifetime compared to her great-grandmother.
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The fluid lost during a period is only partly blood. The percentage of blood in the fluid varies from 1.6 to 82% the average being 36%. Some women with heavy flow may be losing very little blood although the loss of other fluid may be troublesome and account for fluid loss symptoms such as fatigue and exhaustion.
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What range of menstrual cycle flow is considered to be normal?
We time periods from the first full day of menstrual loss as Day 1. The menstrual cycle duration is timed from the first day of one period to the first day of the next. We consider menstrual cycles of less than twenty-one days to be too short, and they are too long if the cycle exceeds 35 days. The first day of the last period is called the last menstrual period or LMP.
How can menstrual blood loss be measured?
In routine clinical practice, the number of pads or tampons used for each period gives an indication of blood loss, although some women may change these more often than others. Passage of blood clots indicates heavy loss. Some women require double protection which is another indicator of heavy loss. There are charts that allow you to indicate the number of tampons and sanitary towels that you are using and how heavily these have been stained. These charts correlate with more scientific estimations of blood loss. The recent development of absorbent sanitary wear tends to preclude accurate assessment with these charts.
Laboratory methods have been established for exact measurement of menstrual blood loss. All sanitary wear is collected and the blood is extracted and measured. This is unpleasant for patients and staff and it is only used in research. The technique proved invaluable in establishing normal menstrual blood loss and defining abnormality. Laboratory measurement of menstrual blood loss is regarded by the perfectionist as the gold standard in evaluating new treatments. This research has shown that the average period blood loss is 40-60 mls (8-12 teaspoonfuls). Some women losing up to 400 mls do not realise that they have a problem (500mls is about a pint). Other women may complain of excess loss when they are losing less than 10mls.
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How can I tell if my menstrual blood loss is abnormally heavy?
A noticeable increase in blood flow during menstruation, or bleeding between periods (inter-menstrual bleeding IMB), is abnormal and should be reported to your doctor. Periods lasting more than 7 days or occurring more frequently than every 21 days are abnormal.
It is difficult for a woman to quantify her own loss. An increase in the requirements for sanitary wear indicates a change in pattern. Blood clots or flooding are indications of heavy
menstrual period loss. Normally the blood lost from the vessels in the lining of the womb forms small clots and this tends to reduce the flow. The small blood clots within the uterus are broken down by chemicals called fibrinolysins and the normal menstrual loss should be a fluid. When the bleeding is heavy, the blood is extruded too quickly for it to clot within the uterus. In this situation, the blood clots in the vagina and the menstrual flow includes blood clots. Whilst menstruation is inevitably an inconvenience, it should not result in limitation of social activity.
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What could be the cause of my heavy periods?
- In at least 50% of patients with menstrual disorders, including heavy periods and bleeding between periods, there is no obvious explanation; we call this dysfunctional uterine bleeding. Furthermore, the fact that fibroids, for example are found in a patient with heavy periods, does not prove that the fibroids are the cause of the problem. The periods may be heavy even if the fibroids were not present (Q4.3). The same would be equally true for other abnormalities including endometriosis.
- Fibroids (fibroids).
- Endometriosis(Q 23.18) is a condition where tissue similar to the endometrium (lining of the womb) is found in other sites usually around the pelvic area.
- Adenomyosis (sometimes called internal endometriosis) is a condition where endometrial-type (lining of the womb) tissue can be found in the muscle wall of the uterus. When there is adenomyosis, the uterus is enlarged and may be tender. Ultrasound may suggest adenomyosis but the diagnosis can only be confirmed when the uterus is examined following hysterectomy.
- Pelvic inflammatory disease (Q 20.2).
- Conventional intra-uterine contraceptive devices - IUCDs (Q17.1).
- Endometrial polyps (a polyp is like a skin-tag;Figure 24.1).
- Occasionally, the development of the uterus may have been abnormal (congenital uterine abnormalityQ6.5).
-
There is some evidence that adiposity increase the incidence of heavy
periods and the need for hysterectomy and adiposity is increasing.0801
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Does sterilisation result in heavy periods?
At one time it was suggested that female sterilisation increased period loss. This change in the periods is now thought to be related to stopping the pill around the time of sterilisation.
Women on the combined oral contraceptive pills tend to have light periods. When the pill is discontinued after sterilisation, the periods return to the loss that would have been experienced without the benefit of hormonal control. There is no difference in the bleeding pattern of women who have undergone sterilisation compared to women whose partners have had a vasectomy. One study, however, found an increased incidence of hysterectomy following female sterilisation.
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Should I have tests to find out why my
periods are heavy?
This depends on your age and the severity of the bleeding. A blood count should be considered at any age as heavy bleeding can result in anaemia, which can be corrected with tablets containing iron. Teenagers and young women are likely to be particularly anxious, as they may be concerned that they will prove to have a fertility problem in due course. Furthermore, younger women tend to be more physically active and may particularly resent the limitations imposed by period problems. An ultrasound examination of the pelvic organs will usually provide reassurance. It may be prudent to check that the blood clotting mechanism is normal, particularly if there is a story of bleeding problems in the family or if you bruise or bleed very easily.
From late teens through the twenties and thirties, when obvious problems have been excluded, further investigation may be necessary only if the bleeding is extremely heavy or if it fails to respond to medication.
A physical problem becomes more likely in the forties and fifties. Visualisation of the uterine cavity by means of a hysteroscope (thin telescope Figure 24.2) and biopsy of the lining of the womb (cervical dilatation and endometrial curettage,
hysteroscopy D and C) are generally recommended by gynaecologists when medication fails to provide improvement.
It is usual for your doctor to record the details of your problems and you will probably be examined. The story together with the examination findings may indicate the cause of the problem. A blood count is required to exclude anaemia resulting from the excessive blood loss. Ultrasound of the pelvic organs may be considered. Introducing fluid into the uterus may enhance the accuracy of transvaginal ultrasound. Sometimes a biopsy from the lining of the womb (endometrial biopsy) is taken in the clinic. Frequently, particularly in women aged 40 or more, a D and C and hysteroscopy is performed (hysteroscopy D and C; Q 24.12) when there is no response to medication.
In younger women, particularly if there is a tendency to bruise or bleed easily, tests to check that the blood clotting mechanism is normal may be indicated.
There is no indication for testing the thyroid routinely as part of the investigation of heavy periods. Thyroid function tests should be considered if there is any other suggestion of possible clinical thyroid disorder. Hypothyroidism (underactive thyroid) is more likely to be associated with heavy periods than hyperthyroidism (overactive thyroid). Picture charts of menstrual loss have been helpful but the newer absorbent sanitary wear has decreased their value.
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What is meant by anaemia due to heavy periods?
Heavy periods
may lead to anaemia as blood loss exceeds blood replacement.
Blood consists of fluid (plasma) and cells. The cells are the white blood cells, which protect against infection and the red blood cells, which carry oxygen from the lungs to the tissues of the body. The pigment in the red blood cells that carries the oxygen is called haemoglobin. Iron is an important part of haemoglobin. We absorb iron from certain foods including meat. There are also platelets, which are the tiny bricks in blood clots the body's mechanism to stop bleeding.
When blood is lost from the body, new blood cells must be produced to replace the loss. If periods are heavy for more than a few months, iron may be lost faster than it can be replaced and this is reflected in reduced haemoglobin concentrations. The average haemoglobin level is 14.6 g/dl (grams per 100ml). Anaemia means that the haemoglobin has dropped below 11.5 g/dl. There are other causes of anaemia including blood loss from the stomach and intestine and inadequate absorption which can be due to inadequate intake (e.g. malnutrition or special diets). Occasionally there may be deficiency of other essential requirements particularly vitamin B12 or folic acid. Some people are born with abnormal haemoglobin (e.g. sickle cell disease or thalassaemia which are more common in people from African or Mediterranean countries respectively).
What is meant by intermenstrual bleeding?
Intermenstrual bleeding (IMB) is bleeding between periods that is not associated with intercourse (post-coital bleeding – PCB). Bleeding about fourteen days before periods may be related to ovulation (Q 2.3) or a little bleeding for a day or two before the period begins properly (premenstrual spotting) may be more of a nuisance than a medical anxiety.
There are a variety of causes for IMB. The bleeding may be coming from the cavity of the womb with causes including those for heavy periods (Q 24.6). The bleeding could be arising from the cervix or vagina. Whereas heavy regular periods are almost invariably due to benign conditions, intermenstrual bleeding can occasionally be the first indication of more worrying disease.
Physical examination by your doctor should detect problems around the cervix or the vagina. Serious disease within the uterus is unusual before the age of forty. If you are less than forty years old, hormone treatment may resolve the problem. If the IMB persists despite medication or if you have reached forty, further investigation including hysteroscopy and endometrial curettage are usually recommended.
A forty-five year old lady had been happy with a LNG- intrauterine system (Mirena) for three years. She then developed a little irregular bleeding. On examination her uterus was a little bulky but there were no other problems. Ultrasound demonstrated a few small fibroids. Endometrial biopsy showed inflammation and progestogen effects. The bleeding settled completely with a course of antibiotics.
A thirty-eight year old lady presented with intermenstrual bleeding. She had one child but then had difficulty conceiving. She was overweight and there had been evidence of PCO ( Q7.1). Hysteroscopy and D and C ( hysteroscopy D and CQ 24.12) were performed. The histology (
Q 2.1) of the endometrium (lining of the uterus) demonstrated severe atypia (abnormal cells) and after full discussion hysterectomy ( hysterectomy) with bilateral salpingo-oophorectomy (removal of both ovaries and Fallopian tubes - Q 24.23) was performed. The histology of the uterus showed foci of malignancy. As the malignancy was detected early, radiotherapy was not required and the prognosis is excellent.
What is meant by a hysteroscopy and D and C?
D and C involves the dilatation of the cervix (neck of the womb) and curettage (a curette is a surgical spoon) to "scrape" representative samples of the lining of the womb. These "curettings" are sent to the laboratory and examined under the microscope. These days most gynaecologists combine the D and C with hysteroscopy (Q 24.8). Polyps or fibroids distorting the cavity of the womb may be diagnosed or excluded. The D and C is generally recommended to ensure that the lining of the womb is not seriously abnormal (for women aged 40 or more) before commencing medical treatment.
For many years it was believed that the D and C had a therapeutic effect. It is now recognised that the first period after a D and C may be lighter but there is no long-term improvement. It should be emphasised that the D and C, like a blood test or an x-ray, is a diagnostic procedure and not a treatment.
What is cervical cautery?
If there is cervical ectopy (cervical erosion) the inner lining of the cervix has come on to the vaginal surface (Figure 21.3) or if there is chronic inflammation (cervicitis cervical erosion), your gynaecologist may wish to take the opportunity of cauterising the cervix whilst undertaking a hysteroscopy and D and C for you. Cervicitis and cervical ectopy may be a cause of vaginal discharge, post-coital bleeding or intermenstrual bleeding (Q 24.11). Cervical cauterisation destroys the ectopy or cervicitis and allows a healthy covering to develop.
What happens after the D and C?
The first period or two following a D and C may be early or late, light or heavy. About 7-10 days following cautery there may be a little bleeding when the scab comes away. In the unlikely event that the bleeding seems worryingly heavy you should contact the hospital.
We recommend that for three weeks after this operation, tampons should not be used and sexual intercourse should be avoided.
Several factors including age, fertility requirements, duration and severity of the heavy bleeding will influence decisions. Concurrent problems such as pelvic pain and premenstrual syndrome may influence clinical advice but you should be presented with all relevant information to help you plan with your doctor the most appropriate choice. Treatment may depend on the underlying cause for the heavy loss. Medical and surgical treatments (Figure 24.3) as well as a special intra-uterine contraceptive device, the levonorgestrel intrauterine system (Mirena;
Figure 14.1) are available.
Figure 24.3
Figure 14.1 Mirena IUS In Uterus
We can consider specific interventions for a particular cause of the heavy loss such as removing fibroids or an intra-uterine contraceptive device. As previously stated, your periods may be heavy despite the presence of fibroids or endometriosis and not necessarily because of them. Fibroids, endometriosis or an intrauterine contraceptive device may be found in association with heavy periods but that does not necessarily mean that they are unequivocally the cause in every patient. It may be appropriate to offer treatments used in dysfunctional uterine bleeding (Q 24.17) even in the presence of these conditions. When there is a possible cause for heavy periods, such as fibroids, skilled judgement is required to decide whether specific treatment such as myomectomy (Q 23.17) is required or whether to offer a non-specific treatment such as tranexamic acid.
Every gynaecologist has a personal preference resulting from a combination of education, experience and sub-speciality interests. We should ensure that you are aware of all the options so that you can make an informed choice.
Heavy and irregular periods may respond to progestogens, particularly at the extremes of the reproductive years. Women with menopausal symptoms commencing cyclical hormone replacement therapy often report improvement in their periods. This probably relates to the fact that they are having anovulatory cycles (eggs are not being released) and the cyclical progestogen in the HRT is replacing the progestogen deficiency.
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What Medical treatments for available for my
heavy periods?
Medications used include:-
How do medical treatments for heavy periods
work?
A: Combined oral contraceptive Pill.
During the first 14 days of a natural menstrual cycle, the lining of the womb (endometrium) is stimulated by oestrogen alone. Under the influence of the oestrogen the endometrium becomes thicker (proliferates Figure 2.3). Following the release of the egg (ovum ovulation), about 14 days before the next period is due, the endometrium comes under the influence of progesterone as well as oestrogen. The combined oral contraceptive pills contain combinations of oestrogen and progestogen (Q16.1). Each pill contains both hormones. They are usually taken cyclically for 21 days with a 7-day gap. One of the effects of the progestogen is to keep the lining of the uterus thin so that in the event that an egg is fertilised, the lining of womb cannot allow implantation, thus preventing pregnancy. As the endometrium is relatively thin and underactive, the monthly withdrawal bleeds tend to be lighter.
B: Progestogens
The standard textbook recommendation is that progestogens should be taken in the second half of the menstrual cycle e.g. From day 16 to 26. The logic behind administering the progestogen in the second half of the cycle seems to be that in the natural cycle this is the time that the ovaries are releasing progesterone. When young teenage girls or peri-menopausal women are troubled by heavy periods, cyclical progestogens taken in the second half of the menstrual cycle may confer benefit. In these situations, there is often evidence of anovulation (eggs are not being released) so that there may be oestrogen but no cyclical release of progesterone.
The majority of women with heavy periods, however, are ovulating indicating that their progesterone levels are normal. Most of the evidence would suggest that progestogens given in the second half of the cycle do not reduce blood loss. There have been suggestions that progestogens, may reduce period loss when they are given much earlier in the cycle, perhaps from day 5 to day 26. This would be compatible with the twenty-one day course of progestogen given in the combined oral contraceptive pill. It should be noted that the progestogen alone does not provide contraception.
If there is any likelihood of pregnancy occurring, dydrogesterone (Duphaston - Solvay) tends to be my first recommendation: Duphaston is licensed for use in pregnancy for women who recurrently miscarry. There is some reassuring data that medroxyprogesterone (Provera Pharmacia and Upjohn) has no detrimental effect on a fetus. Norethisterone (Primolut N Schering; Utovlan - Searle) could cause problems (masculinisation) to a female fetus, although this is not a problem in the early weeks of pregnancy. Nevertheless, before administering norethisterone, one would wish to emphasise the particular need for contraception.
C: Tranexamic Acid(Cyklokapron Pharmacia and Upjohn).
During each period, the blood lost from the vessels within the womb should clot (coagulate). As with a cut or a graze, the clot tends to stop the bleeding. Fibrin is an essential part of the blood clot. Fibrinolysins (lysis Greek, a loosening) in the cavity of the womb break down the clot so that the period loss is normally fluid. Tranexamic acid reduces this fibrinolytic activity so that the tiny blood clots sealing the bleeding vessels can continue to function for longer thus reducing the period blood loss. There is no reason to withhold tranexamic acid before investigation such as hysteroscopy and D and C. Two or three tablets three or four times daily as and when required would be the recommended dose. Tranexamic acid should not be taken if you have a history of thrombosis (a blood clot surgery risks).
D: Mefenamic Acid and other prostaglandin synthetase inhibitors - non-steroidal anti-inflammatory agents (NSAIs).
Prostaglandins are a group of hormones that have a variety of functions. They derive their name from the prostate gland (a gland of the male reproductive tract) although they are produced in other tissues including the endometrium. Endometrial concentration of prostaglandins is increased in association with menorrhagia. Prostaglandin synthetase is an enzyme (a chemical that acts as a catalyst promoter of a chemical reaction) that is crucial to the production of prostaglandins.
Prostaglandin synthetase inhibitors, also called 'non-steroidal anti-inflammatory agents', have a variety of valuable therapeutic uses. These include treatment of pain in general and arthritis in particular. Most of the research in relation to menorrhagia relates to mefenamic acid (Ponstan) although there are others in this group, including naprosyn, ibuprofen, indomethacin and diclofenac that may also prove effective. Mefenamic acid has been shown to reduce menstrual blood loss significantly. It tends to be of particular value when treating a combination of menorrhagia and dysmenorrhoea (painful periods). NSAIs are not recommended if you have a history of peptic ulcers or asthma.
E: Gonadotrophic Releasing Hormone Agonists.
Gonadotrophin Releasing Hormone (GnRH) is released by the hypothalamus and results in release of the gonadotrophins, FSH and LH, which in turn stimulate ovarian follicular development (Figure 2.6). Gonadotrophic releasing hormone agonists are used to block GnRH production in a variety of gynaecological situations. They can be used to stop the menstrual cycle and thus stop periods.
As oestrogen levels fall, menopausal symptoms (Chapter26) are common. Prolonged suppression of ovarian function will lead to osteoporosis (weakened bonesQ 26.24) and disease of the arteries. GnRHs can be used for a maximum of six months by themselves. They are extremely valuable in preparation for removal of fibroids (Q 23.17) and occasional situations such as stopping periods in patients with severe menorrhagia when blood transfusion is not an option (e.g. Jehovah's Witnesses). GnRH can be used in combination with HRT (add-back therapy) for longer than six months. GnRH treatment is extremely expensive precluding its prolonged use except in extreme situations.
F: Hormone Replacement Therapy (
HRT)
Menorrhagia beyond the age of forty years should be investigated (Q 24.9). Frequently women presenting with menopausal symptoms and menorrhagia, report reduced menstrual flow after cyclical HRT has been commenced. The menstrual cycles before the menopause are often anovulatory (eggs are not released). There is, therefore, progesterone deficiency in the second half of the cycles and the progestogens in the cyclical HRT would account for the improvement in the periods.
G: Danazol
Danazol (Danol Sanofi Winthrop) seems to be active in a number of areas of the reproductive system. It has some gonadotrophin inhibitory activity. It may also have a direct action on the endometrium. At higher dosage levels, it frequently induces side-effects particularly sickness. At lower dosage, such as 100mg daily, side-effects are less common and yet heavy menstrual flow may be reduced.
H: Gestrinone
This agent seems to have similar modes of action to danazol. It is longer acting and a typical dose would be 2.5mg twice weekly.
I: Ethamsylate.
This drug seems to increase capillary wall strength, increase platelet stickiness and reduce some of the adverse effects of prostaglandins (Q 24.17D). There is less convincing evidence of benefit with heavy periods.
J: Antibiotics.
Clearly when there is evidence of pelvic inflammatory disease (Q 20.2) antibiotics are likely to be beneficial. It is possible that there may at times be sub-clinical bacteria within the uterus (bacteria endometrialis) that may account for some otherwise unexplained menstrual disturbance.
A 34 year old lady had been investigated for intermenstrual bleeding and a polyp was removed. She presented again two years later as her periods had become extremely heavy on the first day for nearly a year. Clinical and ultrasound examination showed no obvious abnormality. Tranexamic acid (Q 26.16:C) to be taken during heavy loss and a course of erythromycin and metronidazole (antibiotics) were prescribed. She returned for review three months later. The tranexamic acid had not been required as her periods had returned to normal following the course of antibiotics.
There is evidence that intrauterine infection may be associated with bleeding between periods that may respond to antibiotics. Controlled trials (Q33-26) would be required to evaluate the potential benefit of antibiotics for dysfunctional uterine bleeding.
K: Hyoscine butylbromide, (Buscopan)
This agent relaxes smooth muscle and therefore reduces uterine contractions. It may be considered in the management of dysmenorrhoea.
L: The levonorgestrel intrauterine system (Mirena)
This device was developed primarily for contraception (Mirena). It steadily releases a tiny amount of the progestogen levonorgestrel within the cavity of the uterus ? equivalent to two progestogen only tablets each week. This results in the lining of the uterus (endometrium) staying in a thin underactive (hypoplastic) state. As the endometrium is thin, the menstrual loss is reduced. There may be initial spotting through the first weeks after insertion but this will almost invariably settle. The device may be introduced in the clinic or at completion of hysteroscopy and D and C (Q 24.8).
M: Depo-Provera
This provides contraception and often periods become light or absent (Depo-Provera).
What treatments for heavy periods are there for a young woman?
Teenagers and young women wishing to retain their fertility generally require medical treatment. The combined oral contraceptive pill is frequently an effective first choice for younger patients particularly when there is need for contraception. Teenagers with heavy periods may be having anovulatory (eggs are not being released) cycles; progestogens taken in the second half of the cycle may be effective and are frequently favoured by parents with understandable concerns about starting their young daughter on the pill. Tranexamic acid, two or three tablets taken three or four times daily, on the usually heavy period days is otherwise a sensible first choice. When pain accompanies the heavy loss, a non-steroidal anti-inflammatory agent may be appropriate. Mefenamic acid 500 mg three times daily is a popular selection.
How do we decide the best treatment option for my period problems?
It is essential that you should be aware of the options available. Age and
fertility requirements are the first concern. Clearly hysterectomy must be
avoided until the family has been completed. The severity of the problem and
its duration must be taken into account. Other factors, such as pelvic pain
or premenstrual syndrome may influence the decision. Some women feel that
hysterectomy is unnatural or defeminising or there may be cultural influences making hysterectomy unacceptable. For others with a family history of ovarian or uterine cancer, hysterectomy may provide reassurance. Your treatment should be influenced by your requirements. Only you can determine how much your periods are affecting you. Frequently there is a combination of problems e.g. heavy periods and premenstrual syndrome or a requirement for sterilisation. Ultimately, the choice of treatment is yours to make from the full information provided by your doctor. On one operating list recently there were three patients with heavy periods. One aged 39 elected to have hysterectomy with removal of only her right ovary (she had right sided pelvic pain). The second, aged 42, chose insertion of a Mirena IUS at the time of hysteroscopy and D and C and the third aged 37 had requested thermal balloon ablation of the endometrium.
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