Menorrhagia

Overview

By Tina Shahian, PhD

Menorrhagia is defined as heavy periods, or excessive uterine bleeding, lasting over seven days. The classic definition for menorrhagia is the loss of greater than 80 mL of blood per cycle, but this metric is no longer used in the clinic due to the difficulty of obtaining accurate measurements from patients. Instead, physicians use the frequency of tampon change to diagnose the disease. This condition disrupts routine activities and can be very emotionally stressful for the women involved.

The most common complication associated with menorrhagia is anemia – a lower than normal red blood cell count, which leaves the body feeling weak and tired. In some cases women also experience severe menstrual cramps that require medical intervention.

Menorrhagia is treatable with drugs or surgical therapies that include a hysterectomy (complete removal of the uterus). The choice of treatment depends on the symptoms, patient’s age, other health factors and intent to have children. Menorrhagia affects 30% of reproductive-age women in the United States. 30% of hysterectomies performed before the age of 60 are due to menorrhagia.

Illustration showing cross-section of uterus

Causes and Risk Factors

The exact cause of menorrhagia is not known, but an imbalance in the amounts of female hormones progesterone and estrogen plays an important role. The following are known causes and risk factors for menorrhagia:

  • Hormonal imbalance. The hormones estrogen and progesterone regulate the menstrual cycle in women and are responsible for thickening of the innermost uterine lining (endometrium). Shedding of this lining results in the bleeding associated with a period. An imbalance in the levels of estrogen and progesterone can lead to excessive thickening of the endometrium and heavier bleeding as it sheds. Dysfunctional ovaries can cause such an imbalance by inhibiting the production of progesterone.
  • Age. Girls in their first year of menstruation and women approaching menopause (ages 40–50) are most likely to have irregular menstrual cycles without ovulation (releasing an egg). This directly reduces the amount of progesterone hormone and causes heavy bleeding during menstruation.
  • Uterine tumors. Benign growths in the uterus such as polyps and fibroids, which appear in woman of reproductive age, can cause heavy menstrual bleeding. Uterine, ovarian and cervical cancers also pose a small risk for developing menorrhagia.
  • Pregnancy complications. A miscarriage or an ectopic pregnancy (where the fertilized egg implants in the fallopian tube instead of the uterus) can also cause menorrhagia.
  • Intrauterine device (IUD). An IUD is a small contraceptive device that is inserted into the uterus. Heavy uterine bleeding is a known side effect of IUDs.
  • Bleeding disorders. Von Willebrand disease (VWD) or platelet function disorders are inherited conditions where specific proteins required for blood clotting are absent, hence the higher risk of menorrhagia.
  • Other disorders. Pelvic inflammatory disease; liver, kidney, or thyroid disease; and endometriosis and adenomyoses (different conditions involving the ectopic growth of endometrial tissue) may increase the risk of menorrhagia.
  • Medication. Anti-inflammatory and anticoagulant drugs pose the risk of heavy and/or prolonged periods.

Symptoms

The following symptoms may be indicative of menorrhagia.

  • Saturating multiple sanitary pads or tampons per hour
  • Requiring two sanitary pads to contain uterine bleeding
  • Waking up at night to change sanitary pads or tampons
  • Prolonged bleeding that lasts beyond a week
  • Passing large blood clots
  • Inability to engage in routine daily activities
  • Fatigue and weakness (signs of anemia).

Diagnosis

The phrase “heavy bleeding” is open to interpretation by patients and is not a reliable metric for diagnosing menorrhagia. Most women with this condition experience bleeding that lasts more than 7 days (4–5 days is typical), and lose greater than 2–3 tablespoons of blood. The need to change sanitary protection almost every hour is a key diagnostic sign of menorrhagia. Other tests used to diagnose menorrhagia include:

  • Blood test. Blood tests are performed to look for iron deficiency (a symptom of anemia), and other conditions associated with menorrhagia, such as thyroid disease and disorders affecting blood clotting.
  • Pap test. During a pap exam, cells from the cervix are collected and tested for signs of infection, inflammation and cancer.
  • Endometrial biopsy. Tissue sample from the endometrial lining is collected and tested for signs of inflammation, cancer and other abnormalities. This procedure causes some pain and discomfort similar to a menstrual cramp.
  • Imaging. An ultrasound test uses sound waves to produce an image of the uterus, pelvis and ovaries, and can help physicians detect physical abnormalities. In a related procedure called sonohysterography, a liquid is injected in the uterus prior to performing an ultrasound. The injected liquid allows a more detailed visualization of the uterine wall, in comparison to a regular ultrasound.
  • Hysteroscopy. This exam allows direct visualization of the uterus via a tiny camera that is inserted through the vagina and cervix.

Treatment

A range of treatments are available to lessen the symptoms of menorrhagia or cure it. The choice depends on the patient’s age, medical history, ideal outcome and future plans to have children. Surgery is generally reserved for patients who do not respond to drug therapies.

  • Hormone therapy. Oral contraceptive pills, hormonal IUDs and hormone (estrogen & progesterone) pills can reduce bleeding by restoring the proper balance of hormones and making periods more regular.
  • Other drugs. Iron supplements can address the iron deficiency associated with anemia. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can alleviate menstrual cramps and reduce blood loss. Drugs that help clot blood or prevent clot breakdown are available for patients with blood-clotting disorders.
  • Fibroid removal. Heavy bleeding caused by fibroids can be treated by shrinking the fibroids. Uterine artery embolization cuts off the blood supply to fibroids, while focused ultrasound ablation destroys fibroid tissue using sound waves; both procedures help reduce the size of problematic fibroids. Uterine fibroids can also be surgically removed using a procedure called myomectomy, which is performed either via small incisions in the stomach or by directing surgical tools through the vagina and cervix.
  • Endometrial removal. Removing, or thinning, the endometrial lining can help reduce heavy bleeding in women with menorrhagia. In endometrial ablation the tissue is destroyed, while in endometrial resection tissue is physically removed. Women who undergo these procedures are advised against becoming pregnant.
  • Dilation and Curettage (D&C). This procedure reduces menstrual bleeding by removing tissue from the uterine lining. First, the cervix is dilated (opened) and then tools are inserted to scrape or suction the tissue. Multiple D&C treatments may be necessary if menorrhagia symptoms reoccur.
  • Hysterectomy. Women who continue to suffer from symptoms of menorrhagia and do not wish to become pregnant may consider a hysterectomy, which is the complete removal of the uterus. Following a hysterectomy a woman stops having menstrual cycles and can no longer become pregnant. This procedure is performed under general anesthesia and requires hospitalization.

Prevention

Currently there is no way to prevent most causes of menorrhagia. The likelihood of developing pelvic inflammatory disease, which is a known risk factor for menorrhagia, can be lowered by avoiding unsafe sexual intercourse and other activities that cause infection.

Sources

  • “Heavy Menstrual Bleeding". Centers for Disease Control and Prevention (CDC). Retrieved Nov 20, 2014. http://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html.
  • “Menorrhagia". Mayo Clinic Foundation. Retrieved Nov 20, 2014. http://www.mayoclinic.org/diseases-conditions/menorrhagia/basics/definition/con-20021959.
  • Apgar BS, Kaufman AH, George-Nwogu U, and Kittendorf A. Treatment of Menorrhagia. Am Fam Physician. 2007. 75(12):1813-1819.
  • “Heavy Periods (Menorrhagia). Am Fam Physician. 2007. 75(12):1820.  http://www.aafp.org/afp/2007/0615/p1820.html.
  • El-Hemaidi I, Gharaibeh A, and Shehata H. Menorrhagia and bleeding disorders". Curr Opin Obstet Gynecol. 2007. 19(6):513-20. Review.