Heavy periods - menorrhagia, what can I do about them?
Heavy Periods - Menorrhagia
I will briefly discuss the options, mainly short of surgery, for patients with the common complaint of heavy periods. I see many patients with heavy periods either as a consequence of thyroid dysfunction or I see patients who are anaemic because of heavy periods. I sometimes see patients who feel so dreadful and tired they have not mentioned their heavy periods to their doctor and consequently do not realise the simple examination and assessment they could have and that therapy that is available.
A typical woman's period lasts for around 5 days and she may lose up 2 tablespoons of blood (10-40 ml) of blood. Heavy periods usually last longer than 7 days and/ or the woman passes large clots of blood during the period. This usually represents at least 60ml blood and this is enough to make some women anaemic. Anaemia also reduces quality of life.
Heavy periods are a problem for many women in the UK. They cause discomfort or even pain, and the loss of blood can causes some severe physicial, psychological and emotional stress, reducing quality of life; it limits normal life.
Menorrhagia is heavy but regular menstrual bleeding.
Objective menorrhagia is loss of 80 ml blood per cycle - when this is present two thirds of women have anaemia.
Subjective menorrhagia may be defined as a complaint of regular excessive menstrual blood loss occurring over several consecutive cycles in a woman of reproductive age.
In the UK 5% of women aged 30 - 49 years consult their General Practitioner each year for menorrhagia. About half of women who have a hysterectomy in the UK do so because of menorrhagia, so the management of menorrhagia is incredibly important.
Although heavy periods are common they are rarely due to serious pathology, but a consultation with ones general practitioner is often useful. Any problem that causes the lining of the womb to be larger will be associated with more blood loss. Fibroids are benigh lumps of connective tissue in the wall of the womb, that can increase the surface area of the womb. If glands get blocked they can enlarge (called adenomyosis), causing a larger womb with heavy, uncomfortable periods. Abnormalities of hormones or the womb's response to normal hormones can cause heavy periods. Any inflammation of the lining of the womb, for example a previous infection or irritation from a contraceptive coil, can cause heavy periods.
This is an extremely common problem in women with menorrhagia, so the blood count should be checked. There is a lot of information in the blood count and it is essential it is interpreted by someone who understands all the information. If the woman is anaemic it is sometimes necessary to assess the iron stores, as these can give a guide to treatment.
Occasionally the hormones might be checked.
An examination of the pelvis is often useful, to assess if the uterus is a normal size, sometimes this can be done by ultrasound, but a scan is not always necessary if the examination is normal.
The anaemia can very often be treated at the same time as the menorrhagia. Iron tablets are usually best, they are generally well tolerated but some patients have constipation. If the tablets cannot be tolerated different preparations should be tried, or iron liquid prescribed. Lastly there is the option of intravenous iron which is given in hospital These are all very safe effective alternatives to blood transfusion, which should be very much a last resort in most patients unless the woman has severe anaemia, is very symptomatic, has co-existing cardiorespiratory disease, or surgery is planned soon (and even then one must still be cautious with blood transfusion).
There are lots of options. What might be suitable for a young woman who would like to have children is different from a woman approaching the menopause.
Treatment during the period
The non-steroidal anti-inflammatory drugs (NSAIDs) are cousins of aspirin. While aspirin does not help, the cousins reduce blood flow by about a 20 - 50%. Examples of these drugs are mefenamic acid (Ponstan), ibuprofen or naproxen. They should be taken from the start, or just before the period, till when the bleeding stops. Some can be bought over the counter as they do not need a prescription; they are not contraceptives but can be taken with contraceptives or with tranexamic acid. They can cause stomach upsets and rarely stomach ulcers.
Tranexamic acid 500 mg, three or four times a day can reduce the blood loss by up to 50%. It is taken only from the first day only during the heavy flow, for a maximum of three to four days. It is not a contraceptive, can occasionally cause indigestion and/or diarrhoea (that settles once the tablet is stopped). It can be taken with NSAIDs or the combined contraceptive pill.
Combined Oral Contraceptive Pill
While not suitable for everyone and only available on prescription these drugs, for the right patients, are safe, they provide contraception, reduce blood loss by about 40 % and also reduce pain. They provide more flexible contraception compared to the levonorgestrel-releasing intrauterine system, possible side effects include mood changes, nausea, fluid retention and breast tenderness. The pill is not suitable for women who have had, or are at increased risk of, thrombosis.
Levonorgestrel-releasing intrauterine system (LNG-IUS)
The levonorgestrel-releasing intrauterine system (LNG-IUS) is a small plastic intrauterine device (IUD) that's inserted into your womb and slowly releases a hormone called progestogen. It reduces blood flow by over 90%. For the first three months or so the periods can be unpredictable but this settles down, other possible side effects include breast tenderness, and acne. It acts as an effective contraceptive and must be fitted and removed by a qualified health professional.
Norethisterone is a man-made progesterone. It's taken in tablet form, two to three times a day from days five to 26 of your menstrual cycle, counting the first day of your period as day one. It can reduce blood loss by up to 80%, but it is not an effective contraceptive, nor is it useful for patients trying to conceive as it can inhibit ovulation. Whereas the LNG-IUS can deliver a small dose of progesterone to the womb, the tablets are a higher dose, so the side effects of weight gain, breast tenderness and short-term acne can be troublesome.
Medroxyprogesterone acetate is another man-made progesterone, given by injection that is sometimes used to treat menorrhagia. Bleeding stops completely in 50% of women after a year, the injection has to be done every 12 weeks. It is an effective contraceptive but can have the same progestogen side effects of weight gain, bloating and breast tenderness.
UTERINE ARTERY EMBOLISATION (UAE) or MYOMECTOMY OR HYSTERECTOMY
For women with large fibroids and heavy menstrual bleeding, and other significant symptoms such as dysmenorrhoea or pressure symptoms, referral for consideration of surgery or UAE as first-line treatment is recommended by NICE in England and Wales.
UAE, myomectomy or hysterectomy should be considered in cases of heavy menstrual bleeding where large fibroids (greater than 3 cm in diameter) are present and bleeding is having a severe impact on a woman's quality of life.
When surgery for fibroid-related heavy menstrual bleeding is felt necessary then UAE, myomectomy and hysterectomy must all be considered, discussed and documented.
Women should be informed that UAE or myomectomy may potentially allow them to retain their fertility.
Lastly endometrial ablation is a technique that can be used to treat heavy periods by destroying most of your womb lining with heat, a laser or microwaves. It should stop heavy bleeding. It is fairly quick to perform and the patient can often go home the same day. The woman may experience vaginal bleeding and tummy cramps afterwards, which can last for a few days or weeks The womb lining may grow back, so repeat surgery may be needed Finally, attempting to get pregnant after endometrial ablation is not recommended because the risk of problems like miscarriage is high.
It is worth mentioning hysterectomy briefly., it is a big operation requiring a general anaesthetic and a couple or more days in hospital, as well as a period of time off work.
The rates of hysterectomy have traditionally been too high, but have fallen since the late 80s and 90s; most are performed in the NHS and there are variations around the country, between hospitals and surgeons. Our latest data in the UK indicates one in five women will have a hysterectomy before the age of 60, the rate in the US is closer to one in three! This reduction over time has come about because of less invasive endometrial (lining of the womb) ablation techniques, UAE, the use of the levonorgestrel-releasing intrauterine system (LNG-IUS), and increasingly familiarity with investigating and managing menorrhagia in primary care. That the rate of hysterectomy has fallen is good, that the rate is lower in the UK is good! Most hysterectomies are done for benign reasons, the operation is effective does improve quality of life and is generally cost effective but it is an operation with appreciable risk. The uterus in about half of hysterectomies is found to be normal.
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