Menorrhagia (heavy menstrual bleeding)
Menorrhagia is categorized by prolonged or heavy menstrual periods that typically last greater than 7 days. It can be related to a number of conditions including problems with the uterus, hormone problems or other conditions, such as a bleeding disorder. While heavy menstrual bleeding can make every day activities a challenge, there are treatments to help.
What causes menorrhagia?
During your menstrual cycle, if an egg is not fertilized, the uterine lining breaks down and bleeds. The egg and the uterine lining are then shed from the uterus through the vagina during your period as menstrual blood.
The three main causes of heavy menstrual bleeding are hormonal imbalances, problems with the uterus, and other diseases or bleeding disorders.
Hormone imbalances
The hormones estrogen and progesterone drive the normal menstrual cycle. If estrogen and progesterone are imbalanced, the uterine lining may build up excessively before being shed, causing extreme blood loss during your periods.
Hormone imbalances can be caused by an array of conditions including polycystic ovary syndrome, obesity or diabetes, to name a few. Sometimes a problem with the ovaries can also cause menorrhagia, especially if they stop producing progesterone.
Problems with the uterus
- Endometrial hyperplasia (a condition that causes the endometrium to grow too thick).
- Endometrial polyps (benign growths in the lining of the uterus).
- Pregnancy problems (e.g., a miscarriage, when a fetus dies in the uterus; an ectopic pregnancy, when the fetus grows outside of the womb; or a low-lying placenta called placenta previa).
- Use of certain types of birth control, such as an intrauterine device (IUD).
- Uterine fibroids or uterine polyps (non-cancerous growths or tumors in the uterus that occur during childbearing years).
- Uterine cancer or cervical cancer.
Other possible causes of menorrhagia
- Bleeding disorders such as platelet function disorder or Von Willebrand’s disease, which impairs blood clotting.
- Kidney disease.
- Liver disease.
- Pelvic inflammatory disease.
- Thyroid disease.
Menorrhagia symptoms and risk factors
Symptoms
Menorrhagia symptoms are generally classified by abnormal uterine bleeding, especially in terms of quantity of blood and its appearance.
The following symptoms indicate a problem with menstrual bleeding:
- Feeling exhausted, low-energy and short of breath.
- Feeling constant pain in the lower abdomen during your menstrual cycle, or abnormally painful and intense menstrual cramps.
- Having a menstrual flow in which you pass blood clots larger than or equal to the size of a quarter.
- Having extreme vaginal bleeding that prevents you from doing everyday activities.
- Hygiene products: having menstrual blood loss that soaks through hygiene products (pads or tampons), making you have to change them every 1-2 hours.
- Changing out hygiene products frequently at night to control menstrual bleeding.
- Using multiple hygiene products at a time to control the menstrual bleeding.
- Heavy menstrual bleeding that lasts longer than 7 days.
- Spotting or menstrual bleeding in between your period, at the wrong time during the menstrual cycle (intermenstrual bleeding).
Symptoms of menorrhagia can mimic other conditions or medical problems. Always see your healthcare provider for a proper diagnosis.
Who is at risk of getting menorrhagia?
Menorrhagia is a common problem that affects many people with periods. An estimated 10 million Americans are affected by menorrhagia every year, meaning about 1 in 5 people with periods will experience it.
Your risk for menorrhagia varies with age and other medical conditions. The following may increase your risk of having menorrhagia:
- Anovulation: anovulation means that no egg is released during a menstrual cycle. It is common for adolescents who have just started to get periods, but whose menstrual cycles are not yet fully regulated.
- Being of reproductive age with uterine abnormalities such as fibroids and polyps.
- Being allergic or intolerant to certain medications.
- Insufficient progesterone. Progesterone has a major role in regulating periods. If progesterone levels are too low, due to anovulation or a problem with the ovaries, then excessive bleeding can happen.
- Having a family history of cancer, bleeding disorders or other diseases.
- Having a past history of uterine cancer or cervical cancer.
How is menorrhagia diagnosed?
Diagnosing menorrhagia is challenging, as everyone’s normal level of menstrual blood loss is different. In general, a menstrual period should last 4-5 days with about 2-3 tablespoons of blood loss. A key indicator of menorrhagia is a heavy menstrual flow lasting more than 7 days, with twice as much menstrual bleeding.
Your health history
For a diagnosis, your healthcare provider will ask you about your health history and about your menstrual bleeding and cycle. They may ask the following questions for a better understanding of your situation:
- How old were you when you first got your period?
- How long does your menstrual cycle usually last?
- How many days does your period typically last?
- How many days would you consider your blood flow to be heavy?
- How does menstrual bleeding affect your lifestyle and quality of living?
Your healthcare provider will also perform a physical exam. This includes a pelvic exam to check you for inflammation, scarring or other abnormalities with your uterus such as a fibroid or polyps.
You may be asked to keep track of your periods and how many pads or tampons you use for a few months if you haven’t already done so.
Diagnostic tests
For the clearest diagnosis, your doctor may also recommend one or more of the following tests to see if your menorrhagia may be caused by a bleeding problem:
- Blood tests. Using a needle, a sample of your blood is collected and examined to check for anemia and test how fast your blood can clot. A blood test is also used to see if you may have a hormone imbalance or problems with your thyroid.
- Pap test. For this test, cells are collected from the cervix and examined to check for cancerous changes, infection or inflammation.
- Ultrasound. Using sound waves and a computer, your healthcare provider can check for fibroids or other problems inside the uterus.
- Endometrial biopsy. Examining a tissue sample from the lining of the uterus (endometrium) can help your healthcare provider find abnormal tissue or signs of endometriosis or endometrial cancer.
Other tests may include:
- Hysteroscopy. Using a viewing instrument inserted through the vagina, your healthcare provider can examine the cervix and the inside of the uterus.
- Sonohyterogram. A fluid is injected through a tube in the vagina and cervix into the uterus. An ultrasound scan is then performed to help your doctor look for problems with your endometrium.
- Dilation and curettage (D&C). This procedure is used to find and treat whatever is causing your abnormal bleeding. During a D&C, the uterine lining is scraped and examined to see what is causing the bleeding. Your uterus is also examined.
Treatments for menorrhagia
Menorrhagia can be cured in a variety of ways, depending on how severe your bleeding and symptoms are, as well as your health history, responses to medication and your own personal desires.
Some people with menorrhagia do not want to have a period, some want to better manage and time it, and some simply want to lessen the amount of blood loss. Some want to decrease pain and cramping, and some want to ensure their fertility is not affected. If you have menorrhagia, your doctor will discuss all of your options best with you, from recurrent treatment to one time procedures, medications to surgical therapies.
Medications for menorrhagia
- Desmopressin nasal spray: If you have a bleeding disorder, a nasal spray can help your symptoms by releasing a clotting protein in the lining of your blood vessels to help the blood clot better.
- Hormone therapy: Taking estrogen and/or progesterone can reduce the amount of bleeding and help treat your menorrhagia if it is caused by hormone imbalances.
- Intrauterine contraception (IUC): These hormonal devices are placed in your uterus and release a medication that mimics the hormone progesterone directly into your uterus. This helps regulate periods and reduce the amount of bleeding.
- Iron supplements: If anemia is the cause or result of your menorrhagia, iron supplements will help fortify your blood to carry more oxygen and prevent an iron deficiency. This can help with symptoms like intense fatigue and low energy.
- Nonsteroidal anti inflammatory drug (NSAID): Taking medications such as ibuprofen can help reduce your pain, cramping and lessen the amount of blood loss, but can increase the risk of bleeding for some people.
- Oral contraceptive pill: Hormonal birth control pills regulate your hormones so that you can better manage the timing of your period, and will also reduce the amount of bleeding you experience.
- Tranexamic acid: These medications reduce your amount of bleeding by preventing newly-formed blood clots from breaking down. You only need to take them during your period.
Surgical treatment for menorrhagia
- Dilation and Curettage (D&C). This procedure can be used to diagnose menorrhagia but also to treat it. In treatment, a D&C removes the top layer of your endometrium to reduce menstrual bleeding, but may need to be repeated over time as your endometrium will continue to build back up.
- Endometrial ablation. This surgical procedure uses a laser, radiofrequency or heat to destroy (ablate) part of your endometrium to control dysfunctional uterine bleeding. An endometrial ablation will lighten your blood flow in future periods. However, an endometrial ablation may not be a good option if you are looking to become pregnant in the future, as it increases the risk of pregnancy complications. Permanent birth control until menopause is recommended to prevent these complications.
- Endometrial resection. Similar to ablation, endometrial resection uses a special metal loop heated with electricity to completely remove the lining of the uterus to control heavy bleeding. Like after ablation, permanent birth control is encouraged to prevent pregnancy and complications following the resection.
- Hysterectomy. To completely get rid of menorrhagia by preventing periods altogether, a hysterectomy can be done. A hysterectomy is a major surgery to remove the entirety of your uterus. You will need to stay in the hospital after the procedure, and can no longer get periods or become pregnant.
- Operative hysteroscopy. This surgical procedure helps diagnose menorrhagia and can also treat it. Using a special viewing tool to see inside of your uterus, a doctor can use a hysteroscopy to remove any uterine abnormalities such as fibroids, and remove the endometrium to manage heavy periods.
- Uterine artery embolization. If you have uterine fibroids that cause menorrhagia, a uterine artery embolization shrinks the fibroids by blocking any uterine arteries connected to the fibroids, therefore cutting off blood supply. During this procedure, your surgeon will pass a catheter through your femoral artery (the largest artery in the thigh) and guide it to your uterine arteries. Once the catheter is in the correct location, the blood vessel feeding the fibroid is injected with material to decrease the blood flowing towards the fibroid. Over time, the fibroid will shrink and bleed less.
Despite menorrhagia being a common issue, many people who have it do not know they can be treated for it, or are embarrassed or uncomfortable to discuss their symptoms. Being able to speak openly and promptly to your doctor will make it significantly easier to get the proper diagnosis and treatment necessary.
Can you prevent menorrhagia?
Menorrhagia cannot be prevented, but speaking with your healthcare provider can ensure a fast diagnosis and proper treatment to prevent complications or other health issues.
That being said, it is possible to manage menorrhagia and its symptoms and to live your life without interruption. For days that your symptoms are severe, you can stay home and take medications such as ibuprofen to ease the pain.
It’s also recommended to follow the same practices as with normal menstruation, such as changing your hygiene products, avoiding irritants such as caffeine and using a hot compress for cramping.
References
Center for Disease Control and Prevention (CDC). Heavy Menstrual Bleeding (https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html)
National Center for Biotechnology Information (NCBI): National Library of Medicine. Menorrhagia (https://www.ncbi.nlm.nih.gov/books/NBK536910/)