What is Menorrhagia?
Periods with abnormally heavy or prolonged bleeding.
- Menorrhagia means periods with abnormally heavy or prolonged bleeding that occur every month. Although heavy menstrual bleeding is a common concern, most women do not experience blood loss severe enough to be defined as menorrhagia.
- The amount of blood loss interferes with your quality of life. For example, if it stops you doing normal activities such as going out, working or shopping. It can occur alone or in combination with other symptoms.
- It is difficult to measure blood loss accurately. Some medical definitions of blood loss during a period are: A normal period is a blood loss between 30 and 40 ml (six to eight teaspoonfuls) per month. Bleeding can last up to eight days, but bleeding for five days is average. A heavy period is a blood loss of 80 ml or more. This is about half a teacupful or more.
What are the symptoms of Menorrhagia?
For practical purposes, a period is probably heavy if it causes one or more of the following
- Flooding through to clothes or bedding.
- You need frequent changes of sanitary towels or tampons.
- You need double sanitary protection (tampons and towels).
- Soaking of bedclothes.
- You pass large blood clots.
- Restriction to your normal lifestyle because of heavy bleeding
What causes Menorrhagia?
Unknown cause – About 50% of the time the cause is unknown, this is called dysfunctional uterine bleeding (DUB) or idiopathic menorrhagia. Everything is normal and the periods are usually regular. Heavy periods due to DUB are more common at the start and end of your menstrual life. Sometimes your periods are irregular as well as heavy. If you are a teenager and have heavy periods, they will often settle down over a few years and become less heavy.
Other causes -
- Fibroids. (see fibroid blog)
- Endometriosis. (see endometriosis blog)
- Uterine (endometrial) Cancer.
Hormonal problems. Periods can be irregular and sometimes heavy if you do not ovulate every month. This can occur in polycystic ovary syndrome. Thyroid problems can also cause heavy periods.
The intrauterine contraceptive device. Sometimes a copper IUD causes heavy periods. However, a special hormone-releasing IUD called the intrauterine system (IUS) can treat heavy periods.
Pelvic infections. Some infections can lead to heavy bleeding. Antibiotics can treat them.
Warfarin or similar medicines interfere with blood clotting. If you take one of these medicines for other conditions, heavier periods may be a side-effect.
Chemotherapy can also cause heavy periods.
Blood clotting disorders are rare causes of heavy bleeding. You might notice you bruise easily or cuts bleed for longer than other people’s do.
Stopping the combined pill. Your periods often become heavier when you stop the pill because the pill usually regulates and makes your bleeds lighter. When your normal cycle returns it may seem heavier but is often normal
Do I need any tests if I have heavy periods?
Keep a diary of what’s happening and see your doctor if your periods change and are heavier than before. Often, when we check things out, there is no obvious cause, but we can make sure nothing of concern has caused the changes. A doctor may want to do an internal examination to examine your cervix and to assess the size and shape of your uterus and to feel for your ovaries. However, an examination is not always necessary, especially in younger women who do not have any symptoms to suggest anything other than dysfunctional uterine bleeding.
You may be asked to have a blood test to check for anaemia. If your bleeding is particularly heavy, you may not be getting enough iron in your diet to replace the amount you lose. (Iron is needed to make blood cells.) This can lead to anaemia which causes tiredness and other symptoms. Roughly 7 out of every 10 women with heavy bleeding will develop anaemia.
If there are no other concerns, the diagnosis is usually dysfunctional uterine bleeding. Treatment can be started once the diagnosis is made, to try and control the bleeding. Some women may need further tests if the diagnosis is unclear or you have additional symptoms such as:
- Bleed between periods or have irregular bleeding.
- Have bleeding or pain during, or just after, sex.
- Have severe pain.
- Have a vaginal discharge.
- Have bruising or bleeding elsewhere
What tests could I have for Menorrhagia?
An ultrasound scan of your pelvis. This is either through the pelvis or could be an internal scan. This can tell us if you are suffering from polyps or fibroids.
Swabs. These check for infections and are usually taken from deep inside the vagina and also from the cervix.
Endometrial sampling. This is done using a thin straw like device which is passed through the cervix to get small samples of the uterine lining (endometrium). These are analysed in the lab. This is can sometimes be done without an anaesthetic.
A Hysteroscopy. The doctor passes a thin telescope into your uterus through your cervix via the vagina. This can be done with or without an anaesthetic. Samples of tissue can be taken if anything looks unusual.
Blood tests may be taken to check for anaemia and also to rule out thyroid and clotting problems.
Keeping a menstrual diary
Keeping an accurate diary is a crucial step in the diagnosis of heavy bleeding. You usually need to do this for about 3 months to get a complete picture of your experience. Your Integriti doctor can offer you paper charts but there are many smartphone apps which will also help you to do this. If you can print off the records and bring it to your appointment this can be really helpful. A diary is useful for both patient and doctor to see:
- When you have symptoms and how severe they are.
- Your response to any treatments, it can take a few cycles for treatments to work.
What are the treatment options for heavy periods?
If there is a cause for the bleeding, such as fibroids or infection, these can be specifically treated. If you suffer from dysfunctional uterine bleeding, no obvious cause will be found.
In this case, the aim of treatments is usually to reduce the bleeding to a level you can cope with and to replenish your iron stores.
Not treating -If you are happy with the knowledge that nothing serious is causing increased bleeding, you may to choose to do nothing more than check your iron levels periodically.
Tranexamic acid tablets – This will reduce blood flow by up to 60% for some women. You usually take it for the first 3 days of your period until the bleeding is light enough to cope with. It won’t change how long you bleed for or have any impact upon your pain. However, the number of days of bleeding during a period is not reduced and neither is period pain. Side-effects may include an upset stomach.
Anti-inflammatory painkillers -You can buy anti-inflammatories from the chemist. They reduce pain and can also reduce blood flow by up to 20%. You can take them for the first 3 days of your period. If you use them alongside tranexamic acid they can work very well together. They aren’t suitable for everyone so check with your doctor if you are not sure if you can take them.
The combined oral contraceptive (COC) pill -The oestrogen in the combined pill usually regulates and reduces bleeding, by up to 30% in most women. It is helpful for women who are also looking for contraception but don’t want a long acting version. You can take pain relief with it if needed. The nuvaring (vaginal ring) will also work in this way.
Long-acting progestogen contraceptives – The hormonal IUD is often a first line treatment for women with heavy periods. It will stop or make your periods lighter and once removed, your fertility returns to normal for you. The contraceptive depo injection and the contraceptive implant may also reduce heavy periods but are not licenced for this purpose. However, if you require contraception then one of these may be an option for you. See separate leaflets called Contraceptive Injection and Contraceptive Implant for more details (contraceptives section of Integriti site).
Norethisterone is a hormone (progestogen) medicine. This is a tablet that you can take on days 5-26 of your menstrual cycle (day 1 is the first day of your period). This will not act as a contraceptive. Other options are usually more effective and have less side effects. It can also be used in a different way to stop your bleeding if it is particularly heavy.
Other medicines - Other hormonal treatments, such as gonadotrophin-releasing hormone (GnRH) analogues, are occasionally used by specialists in hospital to give you a chemical menopause. Generally side effects mean that this is not often used.
Surgical treatment – Surgery is usually reserved for when medical options either don’t work or aren’t suitable. Procedures to remove the lining of the uterus can be effective but often need repeating over time and are unsuitable for anyone who wants to retain their fertility.
Hysterectomies can be performed but usually only if all other options have been deemed unsuitable or unsuccessful. This is to minimise risks related to an irreversible operation.
It is especially important to understand that the different Menorrhagia management options have various benefits, risks, and consequences. Integriti Clinicians use shared decision-making consultations and decision aids to ensure you are able to make important decisions about your own health. It is always best to speak to a qualified clinician who can help you through the process.
“No decision about you without you”
(please see reference section)