Heavy Periods (Menorrhagia)
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Menorrhagia is heavy menstrual flow of more than 80ml of blood loss with each period. A woman with this condition may also have prolonged periods lasting more than seven days, may use double heavy-duty sanitary pads and may have to change these pads frequently up to every hour. There are often large blood clots (greater than the size of a 10c coin). Such heavy bleeding often affects her daily activities, and if there is anaemia may also cause symptoms such as shortness of breath and lethargy.
Menorrhagia is thought to affect about 1 in 5 women during their reproductive years.
What causes menorrhagia?
Menorrhagia may result from fibroids in the womb (distorting the cavity), polyps in the womb lining, pelvic infections, underlying bleeding disorders and use of copper Intrauterine devices (IUD). There is also a group of women whom we can’t find an obvious reason to explain their heavy periods. These women are thought to have ‘dysfunctional uterine bleeding’. This is thought to be due to a hormonal imbalance and its abnormal actions on the womb. It is more common around the time when the first period starts in early teens (age of menarche) or around the late forties during the ‘change of life’ years (menopause).
Women who are overweight, have medical conditions associated with thyroid problems and diabetes are also more likely to have heavy periods.
Abnormal periods can be associated with uterine cancer, although this is very uncommon under the age of 50.
What tests can be done?
Doctors often start by indirectly assessing the degree of blood loss by measuring the haemoglobin and iron levels in the blood. Sometimes it may be important to check the blood’s ability to clot if this is the first presentation of heavy menstrual flow in a young teenager having her first periods.
Checking thyroid hormone level is also important.
The doctor may also perform some vaginal swab tests to exclude a pelvic infection and organize an ultrasound scan of the pelvis to detect fibroids or polyps. If the doctor suspects a polyp or sometimes something more sinister such as cancer of the lining of the womb, then a biopsy of the womb lining is obtained with a pipelle when you are awake or a curette under general anaesthetic. The doctor may request that you keep a period diary to take note of frequency of pads changed, amount of loss, number of pads used to get an objective assessment of blood loss.
What treatments are available?
- Medical Management
The doctor may start you on some medications to control the heavy bleeding such as an anti-inflammatory medication (NSAIDs), a combined oral contraceptive pills, a drug that promotes clotting such as tranexamic acid, high dose progesterone tablets or by using an uterine device called mirena which is inserted into the womb. The doctor may also start you on iron supplements to prevent anaemia associated with excessive blood loss.
- Surgical Management
The first step involves an evaluation of the cavity of the womb with a hysteroscope. This procedure known as Hysteroscopy, Dilatation and Curettage involves a general anaesthetic and a biopsy of the lining is obtained to exclude polyps, abnormal precancerous changes or more serious cancerous changes. Further surgery would depend on the reason for the bleeding, the age of the patient and the patient’s wishes. Generally if there were no cancerous change, then the treatment could include medical management first. When this fails, surgery may be required to destroy the lining of the womb such as endometrial ablation or resection. When this fails to work or there are other problems such as large fibroids, a hysterectomy may be appropriate. Hysterectomy can be performed either as an open procedure, using keyhole surgery otherwise known as laparoscopy, or as a vaginal hysterectomy if the uterus is not too enlarged.