What is menorrhagia?
Menorrhagia is the medical term for heavy periods, or heavy bleeding, each month. The problem with the term is understanding what constitutes a heavy loss.
A normal period is triggered by the withdrawal of progesterone. This causes a rise of prostaglandins in the lining of the uterus, and this cuts off the blood supply. Without blood flow, the lining of the uterus dies and sheds. The lining is expelled by contractions of the uterus, which are also triggered by the prostaglandin hormone. As the lining sheds, the blood vessels revealed below the lining will bleed until the normal clotting mechanisms within your body stop them.
The definition of menorrhagia is loss of greater than 80mls for each period. But I believe this is a nonsense definition. Who measures their menstrual loss? And how?
With the increasing use of menstrual cups, an environmentally friendly way of managing your period, you do have some chance to formally measure the loss. However, with the more common use of pads and tampons, it is difficult, if not impossible, to measure volume.
The most pragmatic definition of heavy periods is a period that you think is heavy. Heavy periods demand frequent changes of pads or tampons. It is usually difficult to control with the use of tampons, and you may find leaking occurs and that you need to also use a pad, or only pads, to manage the flow.
A heavy period may have episodes of flooding when the loss occurs rapidly, causing blood to run out. You may have disturbed sleep with the need to change the pad or tampon through the night. Some periods are so heavy that the women cannot stray far from a bathroom, and leakage may lead to social embarrassment.
One of the markers of heavy loss is clotting. Blood normally clots, however, menstrual loss contains a chemical that inhibits clotting so that the blood can flow out. If the loss is heavy, there is too much blood for the anti-clot chemical to work, and so the blood clots.
Clots reflect heavy loss, and the size of these clots is an additional marker. Passage of the clots will demand more painful contractions of the uterus.
PhysiologicalThis is perhaps the most common cause, particularly for women in their 40s. After you’ve had children and as you head into your 40s, the uterus is larger than it was before. This means a larger surface area from which to bleed each month. Larger surface area to bleed equals more bleeding.
Adenomyosis is a condition where there is tissue - like the lining of the uterus - growing within the muscle of the uterus. It makes the uterus a little larger and so, as above, this leads to heavier periods. The periods are often more painful due to the increased prostaglandin release within the uterus. This produces more painful uterine contractions, or period cramps. This condition is often only diagnosed when the uterus is examined by a pathologist after hysterectomy.
PolypsBenign growths of the lining of the uterus are a relatively common problem that can cause heavy periods. This will usually improve after removal of the polyps.
Fibroids are a benign growth of the muscle cells of the uterus. Heavier periods caused by fibroids usually reflect the same mechanism as above: there is a larger lining of the uterus that bleeds. It is usually worse if the fibroid is within or very close to the lining of the uterus.
Dysfunctional bleeding - puberty or perimenopause
The same mechanism can occur at either the end of the reproductive life cycle. Infrequent release of eggs can lead to an overgrowth of the uterine lining due to constant oestrogen stimulation and a failure of progesterone production. The thick lining will often bleed heavily for a long time in an erratic fashion. In both situations, progesterone is the solution.
Inherited bleeding problemsInherited bleeding conditions can include Von Willebrands disease, which involve reduced levels of clotting factors in the blood. This means the control of bleeding from the lining of the uterus is slower and loss is heavier.
‘Normal’I have suggested that the practical definition of menorrhagia is any period you perceive to be heavy. Even if you don’t meet the definition of ‘heavy bleeding’, as long as you find it problematic, there is a problem which needs addressing.
Heavy periods after 40
After a pregnancy or three, as you head into your 40s, the uterus will be a little larger than it was before any pregnancies. With a larger surface area, the bleeding with a period will be heavier. Commonly use of the oral contraceptive will have stopped, particularly if your partner has had a vasectomy. When fertility is no longer an issue, women are often and understandably less tolerant of the heavy period that they may have had to endure. It is a common time for women to seek treatment for their periods.
If you are trying to achieve a pregnancy, heavy periods are more of a problem. Clearly, there is a need to exclude underlying problems, as above. In terms of management, most of our treatment options are contraceptive and so treatment becomes more difficult.
Medication for menorrhagia
Occasionally, women will simply want to know that there is nothing serious underlying the heavy periods. With that, they choose to take no further management and iron may be their sole choice of treatment. It will be required if there is anaemia.
- Tranexamic acid:
Tranexamic acid, (trade name Cyklokapron), accelerates clotting in the blood vessels in the uterus that are revealed when the lining is shed. Quicker clotting means less bleeding, and so, a lighter period. This is a good treatment, and will usually significantly reduce blood loss. It is only used during the period and so, it is compatible with women trying to conceive. Its biggest limitation is that the half-life of the medication, the speed with which the body removes the medication from your system, is short. This means you need to take the medication four times a day.
Dysfunctional bleeding, occurring at either end of the reproductive life, reflects oestrogen production without the release of an egg, after which oestrogen and progesterone are produced. Progesterone arrests the growth of the uterine lining and when the levels drop because pregnancy does not occur, the lining is shed due to the loss of progesterone support. If the cycle is not working normally, an oral progesterone tablet will achieve the same effect, stabilising the lining of the uterus. Its withdrawal will produce a synchronous shedding of the lining that will predictably stop. In this situation, regular use of progesterone, perhaps two weeks of each month, will stabilise otherwise problematic bleeding.
- Oral contraceptive pill:
The oestrogen and progesterone in the pill suppress the natural controls of the menstrual cycle. This is often better for dysfunctional bleeding than progesterone alone. Most pills are progesterone dominant. Oestrogen stimulates the lining to grow, progesterone to stop it. With the pill being progesterone dominant, the net result of using them together is that the uterine lining will usually be thinner. This means less to shed and so a lighter period. The effect is often progressive over time, so periods will become progressively lighter. In addition, it is possible to skip the sugar pill for a cycle or two, so the period will occur less often. If too many periods are skipped, breakthrough bleeding will commonly occur. It varies widely between women as to how many periods can be skipped before breakthrough occurs.
The Mirena IUCD is an excellent way to control heavy periods. After the frequent irregular spotting during the first few months on Mirena, the periods usually become much lighter or stop completely. Over the 30 years Mirena has been available, it has been so effective that hysterectomy rates have dropped dramatically. It is a contraceptive, and it takes some time to settle things down, so it best suits women after childbearing.
Endometrial ablation is a relatively simple way to control periods. It can only be used after reproduction is complete, as pregnancy after an ablation is hazardous. It is not contraceptive so it is very important to ensure pregnancy does not occur.
This procedure involves burning the lining of the uterus. There are a number of methods for performing the operation, and significant commercial interests promoting the use of the operation, potentially exaggerating the benefits.
As it burns the lining, the lining bleeds and “weeps” like a burn as it heals, so there is ongoing discharge for a few weeks after the operation.
When the lining heals, it heals with a lining that does not respond to hormones so the periods are usually much lighter or stop.
I will perform an ablation, but I am not a big fan as it has disappointing long-term outcomes. For 25% of women, this method fails within eight years of the operation. The body is excellent at stimulating the lining of the uterus to grow each month, and if just the smallest amount of lining is left, over time it gradually regrows throughout the uterus.
The procedure creates scarring within the uterus so it is difficult to impossible to repeat and usually precludes the use of the Mirena.
It will suit women with a small uterus who are close to menopause.
Removal of the uterus is the definitive way to control heavy periods. Clearly, this is contraceptive and must be done after any consideration of pregnancy. It is the most demanding, and therefore hazardous, way of dealing with periods but may be the most appropriate option, especially if heavy periods are associated with endometriosis, adenomyosis, or fibroids.
Hysterectomy remains one of the highest patient satisfaction operations performed. Women are driven to choose this option by the problems that are happening. To have these troubles absolutely resolved is a very good outcome.