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Heavy Menstrual Bleeding

Normal Periods
A woman normally loses between 30 and 40ml of blood with her period (six to eight teaspoonfuls) each month but there is much variability. Bleeding can last up to eight days, but bleeding for five days is average.

Heavy Menstrual Bleeding
There are medical definitions of heavy menstrual bleeding, but the only practical definition is when there is excessive menstrual blood loss that interferes with the physical, emotional, social and material quality of life. Monthly periods are an individual experience and women who have always had heavy periods will consider this normal. However if you believe that your periods are either unusually heavy, prolonged or both, there are many different treatment options available to you.



Female-reproductive-system-HMB.jpg
                                             Figure 1. Female reproductive anatomy


You may or may not have some of the following problems:

  • Losing more than 5– 6 tablespoons of blood (80mls)
  • Passing clots that are larger than a 50 cent coin
  • Bleeding so much that you have to change your pad/tampon every hour
  • Having to get up most nights to change your pad/tampon
  • Having to put a towel in your bed or use large maternity pads when you sleep
  • Bleeding through clothing
  • Have bleeding that lasts more than eight days (prolonged bleeding)

Heavy menstrual bleeding can result in a drop of iron levels and red blood cells so you may: feel tired more easily; feel weak or dizzy; or be short of breath and have chest pains. Heavy periods can generally be managed using medicine or surgery.


Causes of heavy menstrual bleeding

Heavy menstrual bleeding can be as a result of three main causes:
  • Hormones
  • Changes within the uterus (womb)
  • Blood disorders
Some causes of heavy menstrual bleeding can be identified through investigations. In other cases no definite explanation can be found and it is thought to be a disorder of blood clotting in the lining of the uterus (endometrium), for which no test exists (Figure 1).

Hormone-related problems
Hormone imbalance, often associated with very irregular periods, can affect the lining of the uterus resulting in heavy bleeding.

Common conditions include:
  • Polycystic Ovarian Syndrome (PCOS)
  • Peri-menopause (the time just before menopause when periods stop all together)
  • An underactive thyroid

Uterine-related problems
  1. The uterus can have abnormalities in the muscle of the uterus wall that prevents the uterus from squeezing and contracting well and hence allow blood vessels to continue to bleed.
  2. Fibroids are benign non-cancerous growths in the muscle of the uterus. Fibroids can cause heavy menstrual bleeding, pelvic pressure or pain and problems with fertility and pregnancy. However, fibroid symptoms tend to get better after menopause. Fibroids can bulge from the inside or outside of the uterus. They can range in size from microscopic to the size of a grapefruit or even larger. Fibroids may be removed surgically or reduced in size with medication or by blocking off the blood vessels which supply it. The majority of fibroids are small and do not cause any symptoms at all.
  3. Uterine polyps. These are small growths of non-cancerous tissue that grow from the lining of the uterus(endometrium). Polyps may cause heavy menstrual bleeding, bleeding between periods or bleeding after sexual intercourse. Occasionally, polyps can develop abnormalities, particularly in older women, so it is generally advisable to remove them before they become harmful.
  4. Adenomyosis. This is a condition where the lining of the uterus grows into the muscle wall of the uterus, preventing contraction of the muscle.
  5. Cancer or precancerous changes in the lining of the uterus are rare, but serious, causes of heavy menstrual bleeding.
Women are at an increased risk of developing cancer if they:
  • Are over the age of 45 years
  • Are over 90kg in weight
  • Have never had children
  • Have a family history of endometrial, ovarian or bowel cancer
  • Have polycystic ovarian syndrome
  • Carry a gene that increases their cancer risk
 
Disorders of the blood
Women with certain medical blood conditions, or medicines (“blood thinners”) that stop blood from clotting, can cause heavy menstrual bleeding. 
 
Other causes
Other, uncommon, causes of heavy menstrual bleeding include:
  • Some liver and kidney conditions
  • Occasionally using hormone contraception such as the Pill


What tests might be needed?

  1. Examination: sometimes the bleeding is coming from the cervix, not the uterus itself. Your doctor can examine the cervix to see if this is the source of bleeding. This is done in a similar way as a Pap smear or HPV screening test. 
  2. Blood tests may be ordered to look for anaemia, iron levels, thyroid disease or a bleeding disorder. 
  3. An ultrasound (scan) of your uterus and ovaries (preferably done vaginally) can be used to detect abnormalities in the uterus such as polyps or fibroids.
  4. Internal swabs may be done to exclude any pelvic infection.
  5. A sample of the lining of the uterus may be taken (biopsy) to determine if there are any precancerous or cancerous changes.
  6. A hysteroscopy, which is a procedure used to examine the inside of the uterus using a narrow telescope, may be performed. Samples of the lining of the uterus may be taken at the same time. This can be done either awake or with an anaesthetic. Further information about hysteroscopy can be found on the RANZCOG website under Patient Information.

 

Treatments for heavy or prolonged menstrual bleeding

Treatments are dependent on the following:
  • Cause of bleeding
  • Desire for birth control
  • Whether you wish to have children in the future
  • Other medical concerns you may have

Treatments can be either medical or surgical.


Medical treatments 

Medical treatments can be divided into either hormonal or nonhormonal treatments.

Hormonal treatments use hormones that mimic those in your body, either a combination of oestrogen and progesterone or progesterone alone. The most effective hormone method is the intrauterine device, which releases progesterone hormone into the local area of the lining of the uterus. The device is very effective at reducing blood loss and also prevents pregnancy. It can stay in place in the uterus for up to 5 years. 
The oral contraceptive pill, can be used to control heavy bleeding. Doctors may advise taking the Pill continuously without a break. This is perfectly safe. Other forms of hormonal birth control which can be used to reduce bleeding include a vaginal ring, injection and skin patches.

Non-hormonal treatments aim to decrease blood flow and reduce cramping and pain. The most effective non-hormonal treatment is a drug called tranexamic acid, which allows the
blood to clot more effectively. In this way, it blocks the loss of blood from the uterus. It reduces the flow by approximately 50% though it doesn’t reduce the number of days bleeding occurs.
Anti-inflammatory painkillers – these are also called nonsteroidal anti-inflammatory drugs (NSAIDs) –such as ibruprofen reduce menstrual flow by up to a quarter, but have no effect on the length of time the period lasts.


Surgical treatments

Where medical management has not worked, there are several options to control bleeding:
  1. Hysteroscopy. Polyps and small fibroids can be removed at the time of a hysteroscopy examination.
  2. Laparoscopy (Key-hole surgery) or open surgery. Larger fibroids which are too big or in the wrong position to be removed by hysteroscopy can be removed using these surgical techniques.
  3. Endometrial ablation. This treatment involves using heat to destroy the lining of the uterus. It is only suitable if you do not plan to become pregnant. Endometrial ablation can be done as a day procedure, with most women returning to work the next day.
  4. Hysterectomy. This treatment involves an operation to remove the uterus via keyhole, vaginal or abdominal surgery. Hysterectomy is a permanent cure of heavy bleeding. It would be considered and is discussed when other treatment options have not been effective, are not suitable, or if this is the treatment you would prefer.

Further information about treatment of fibroids, endometrial ablation and hysterectomy can be found on the RANZCOG website under Patient Information.

If you experience heavy menstrual bleeding you should see your doctor. Heavy menstrual bleeding can have a profound negative effect on your life. By discussing your symptoms with your doctor, a number of treatment options can be offered to alleviate the abnormal heavy bleeding and get you back to enjoying life.

DISCLAIMER: This document is intended to be used as a guide of general nature, having regard to general circumstances. The information presented should not be relied on as a substitute for medical advice, independent judgement or proper assessment by a doctor, with consideration of the particular circumstances of each case and individual needs. This document reflects information available at the time of its preparation, but its currency should be determined having regard to other available information. RANZCOG disclaims all liability to users of the information provided.

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