Reasons For Heavy Menstrual Bleeding

Heavy menstrual blood is the most commonly reported menstrual bleeding disorder. It is the excessive blood loss that disrupts daily life activities and interferes with women’s physical social or emotional quality of life.

What is Menorrhagia

Menorrhagia is a medical term used for heavy menstrual bleeding. Average blood loss during normal menstruation is 30-40 ml or 2-3 tablespoons over a period of 4 to 5 days.

Menorrhagia is defined as a blood loss of greater than 80 ml per period or twice the normal amount [1]. This type of bleeding usually lasts longer than 7 days.

If you are passing lumps or clots of blood greater than a 50 cent coin or changing tampon or pad every hour then you need to see your doctor.

Causes:

The etiology of heavy menstrual may be hormonal or structural. Some of the important causes of heavy menstrual bleeding include:

1. Anovulatory Cycle

The most common cause of heavy bleeding in some teenage girls is anovulatory cycles [2].

During the first few cycles after menarche, ovaries usually do not release eggs due to which progesterone hormone is not produced, as it would during a normal menstrual cycle.

The endometrium develops an excess thickness under the influence of high estrogen, which then sheds as heavy bleeding. Same happens in some premenopausal women too.

2. Uterine Fibroids

They are also known as noncancerous tumors of the uterus and are responsible for 30% of heavy bleeding. It is the most common cause of bleeding in childbearing age.

3. Adenomyosis

It is a disorder in which glands and stroma of the endometrium are found deep within the muscular layer(myometrium).

This leads to a tender, boggy uterus and painful heavy bleeding. It is common in multiparous women.

4. Endometrial Polyps

Polyps are finger-like projections from the lining of the uterus into the uterine cavity. They’re a frequent cause of heavy periods.

5. Intrauterine devices

Heavy menstrual bleeding is the most common complication of using non-hormonal intrauterine devices for birth control [3].

You may need to talk to your doctor if you’re having this problem or consider an alternate method of contraception.

6. Hormonal Imbalance

A hormonal imbalance can alter the uterine cycle and result in menorrhagia. There are a number of diseases which produce hormone imbalance including polycystic ovary syndrome (PCOS), insulin resistance, obesity, and thyroid problems.

7. Coagulation disorders

Many coagulation disorders, in which an important clotting factor is missing or platelet are deficient, may cause heavy bleeding during periods [4].

Examples of such coagulation disorders include hemophilia, Von Willebrand diseases, idiopathic thrombocytopenic purpura (ITP), etc.

8. Drug therapy

Anticoagulants such as warfarin, enoxaparin, and aspirin can also play an important role in causing heavy bleeding.

9. Pelvic inflammatory disease (PID)

It is the infection of female reproductive tract involving ovaries, fallopian tubes, uterus, and cervix. PID can be a potential cause of menorrhagia.

10. Gynecological Malignancies

Endometrial or cervical cancer can be the cause of heavy bleeding [5].

Although the usual presentation of endometrial cancer is bleeding after menopause and that of cervical cancer is bleeding after sex.

Nevertheless, heavy periods can be caused by these malignancies.

Other medical conditions like underactive thyroid, liver, and kidney diseases are also associated with heavy menstrual bleeding.

Heavy menstrual bleeding is not always associated with any pathology in younger women so it is important to ask whether it is started at menarche or not.

If it happens since menarche then most likely it is not associated with any pathology.

When to see a doctor:

Heavy menstrual bleeding can also lower your iron or Hb levels that you may feel tiredness dizziness or shortness of breath. 20-30% of women of reproductive age suffer from this disorder.

5% of the women between 30 and 49 years consult their general practitioner with heavy bleeding.

If it is really irritating you and your physical and social life, you need to see your doctor as soon as possible.

A doctor will ask the patient about symptoms and perform an abdominal and pelvic examination in all women complaining of HMB.

This enables any pelvic mass to be palpated, the cervix to be visualized for polyps and carcinoma, swabs to be taken if a pelvic infection is suspected or cervical smear to be taken if one is due.

Investigations

The following test will be helpful for the evaluation of heavy bleeding:

1. A full blood count.
2. Coagulation screen will be done if heavy bleeding is since menarche or family history of any bleeding disorder.
3. High vaginal and endocervical swabs if history indicates an infection of genital tracts.
4. Pap smear to assess cervical infection, inflammation, dysplasia, and cancer.
5. Pelvic ultrasound scan if history suggests structural or histological abnormality such as post-coital bleeding, intermenstrual bleeding. pain/pressure symptoms, enlarged uterus or vaginal mass is palpable on pelvic examination
6. Thyroid function tests will only be carried out when history is suggestive of thyroid disorder.
7. An endometrial biopsy will be considered if risk factors such as age over 45, treatment failure, postmenopausal bleeding or risk factors for endometrial pathology such as intermenstrual bleeding. On transvaginal ultrasound scan, if endometrial thickness appears more than 4mm, then biopsy must be performed.

Treatment:

For some women, loss of a large amount of blood is normal so reassurance is sufficient.

For others, there are a number of medical and surgical options available. Medical treatment gives temporary relief while surgical treatments are contradictory with desired fertility.

So it is important to discuss the management plan before the start of treatment.

Medical treatment:

1. Levonorgestrel intrauterine system (LNG-IUS, Mirena) is the 1st line of treatment for the women who do not want to conceive for the next few years. 95% of reductions in blood loss is achieved with 1-year use.
2. Tranexamic acid, an antifibrinolytic, reduces blood loss by 50% and is taken during menstruation.
3. Mefenamic acid, prostaglandin inhibitor reduces blood loss by 30%.
4. Norethisterone taken from day 6 to day 26 of cycle reduces blood loss.
5. Gonadotropin-releasing hormone agonist act on the pituitary to stop the production of estrogen lead to amenorrhea (absence of menstruation) is also helpful. But it is only used for a short period of time due to its osteoporosis like complication.

There are many surgical options are available like endometrial ablation, uterine artery embolization, myomectomy, transcervical resection of fibroid and hysterectomy.

You must consult your doctor before considering any of the above procedures.

References

1. Quantification of menstrual blood loss. [Link]
2. Adolescent Anovulation: Maturational Mechanisms and Implications, Robert L. Rosenfield. [Link]
3. Quantitative studies on menstrual blood loss in IUD users, Andrade AT, Pizarro Orchard E. [Link]
4. Evaluation of bleeding disorders in women with menorrhagia: a survey of obstetrician-gynecologists [Link]
5. Study Provides Closer Look at Postmenopausal Bleeding and Endometrial Cancer. [Link]
6. Gynecology by Ten Teachers (2012), 19th edition.