Dr Karuna Raja

Heavy/Prolonged/ Abnormal Menstrual Bleeding

Heavy Menstrual Bleeding

The average blood loss in a period is about 30-40 mL (2-3 tablespoons) though, up to 80mL is considered normal. Some women loose much larger amounts of blood. Menorrhagia is the medical term for excessive or prolonged menstrual bleeding. Losing excessive amounts of blood can cause anaemia (lower levels of red blood cells), tiredness and poor quality of life. If the bleeding is acute and severe, it can be life threatening and may require a blood transfusion.

 

Normal Menstrual Cycle

An average menstrual cycle varies between 21 to 35 days (mean is 28 days).  During this time, the uterus, ovaries, hypothalamus and pituitary gland follow a sequence of events that prepare the body for pregnancy.  Two hormones called follicle stimulating hormone (FSH) and luteinizing hormone (LH), are made by the pituitary gland.  These hormones stimulate the ovaries to produce other hormones, progesterone and estrogen.  During the first half of the cycle, FSH stimulates a follicle (egg) to develop in one of the ovaries, this causes the estrogen level to rise, causing the lining of the uterus to grow and thicken.  These events stimulate a rise in the LH level, which ultimately cause the follicle to release an egg from the ovary (ie ovulation).  After ovulation, the ovary produces both estrogen and progesterone, which prepare the uterus for possible implantation and pregnancy.  Progesterone also helps to “stabilize” the lining of the uterus, preventing abnormal bleeding.  If pregnancy does not occur, the estrogen and progesterone levels drop and the lining of the uterus is shed.  The process of shedding is called the ‘menstrual period’.  The menstrual period contains blood and tissue from the lining of the uterus.

 

Causes of Heavy/Prolonged Bleeding

Menstrual bleeding can sometimes be excessive because of abnormal uterine growth growths (eg polyp or fibroids), a defect in blood clotting or no ovulation.

Anovulation - Anovulation occurs when a woman’s ovaries fail to ovulate (produce and release an egg).  Since the normal hormonal changes of ovulation do not occur, the lining of the uterus does not uniformly shed and regrow as in a normal menstrual cycle.  Instead, excessive estrogen stimulates the lining of the uterus (endometrium) to continue growing and become thicker.  Progesterone is not present at the usual levels, which causes the lining to shed irregularly, which may result in heavy and/or prolonged bleeding.  Menorrhagia is adolescents in usually caused by anovulation.  Anovulatory bleeding is also common before menopause (commonly referred to as the perimenopausal period) and with some endocrine disorders such as hypothyroidism and polycystic ovary syndrome.


 

Bleeding Tendency

Menorrhagia can result from conditions that prevent the blood from clotting normally.  Some examples are Von Willebrand Disease, low platelet count or platelet dysfunction and use of anticoagulants (“blood thinners”) such as warfarin.

Uterine Growths - Benign growth in the uterus can cause menorrhagia.  The most common growths are:

  • Polyps - which are small grape like growths of the lining of the uterus.
  • Fibroids or Leiomyomas - which are benign tumors involving the muscle layer of the uterus (myometrium).
  • Adenomyosis - which refers to the growth of the endometrium-like tissue within the muscle layer of the uterus.
  • Cancer or Precancerous Lesions of the Uterus - Rarely, cancer of the endometrium or myometrium can cause menorrhagia. Perimenopausal and menopausal women have more probability of having precancerous and cancerous lesions as a cause of abnormal uterine bleeding.

 

Diagnosis

Diagnosis of menorrhagia is based on history, examination and investigation.  A physical examination is preformed to look for signs of bleeding elsewhere in the body, which could indicate a bleeding disorder.  A pelvic examination will be done to determine the size and shape of the shape of the uterus.  In women with fibroids, the uterus is often enlarged or irregularly shaped.  An endometrial biopsy, in which a small sample of the uterine lining is removed, may be recommended in certain situations.  Laboratory tests are preformed to determine blood count and exclude a bleeding disorder or a thyroid disease.  A pelvic ultrasound is preformed to look for endometrial polyps, fibroids or adenomyosis.

 

The Treatment

The treatment of menorrhagia depends on the cause and severity of the condition, the patient’s preference, the need to prevent pregnancy currently and the woman’s desire to have children in the future.

 

Combined Oral Contraceptives (OCP)

Use of combined (estrogen and progesterone) oral contraceptives decrease menstrual blood loss over time.  Alternatively, contraceptive rings (NuvaRing) may be used instead of the the contraceptive pills.  All of these methods also help to prevent pregnancy.  OCP may be taken in a continuous dosing so you have periods every three to four months (i.e. taking active pills only from two packs and taking active and sugar pills from the third).  This can be continued for as long as desired.  This regimen is particularly suitable for women with painful periods.  Although many women experience breakthrough bleeding with this regimen.  Breakthrough bleeding is inconvenient, but does not mean that there is an increased risk of pregnancy (unless the pills are forgotten).

Progesterone is a hormone made by the ovaries.  A synthetic form of progesterone called progestin, can be given as a pill, injection, implant under the skin or an intrauterine contraceptive device to prevent pregnancy.  Progesterone helps prevent the uterine lining from becoming overly thickened, thus preventing excessive bleeding.

Medroxyprgesterone acetate (Depo-Provera®) is a long-acting progestin that is injected deep into the muscle, such as the buttock or upper arm, once every three months.  Depo-Provera can reduce bleeding in women with menorrhagia, and it also is an effective form of birth control; it prevents pregnancy for 12 weeks per dose.  The most common side effect of Depo-Provera is irregular or prolonged bleeding and spotting- particularly during the first few months of use.  Up to 50% of women completely stop having menstrual periods (amenorrhea) after one year of use.  Menses generally returns within six months of the last injection.  Depo-Provera can cause weight gain and thinning of the blood in some women.

 

Intrauterine Device (MIRENA)

MIRENA is an IUD made of moulded plastic and coated with a progestin hormone.  The IUD is inserted into the woman’s uterus by a healthcare provider.  A thin plastic string is attached to the device (for removal and confirming it’s presence) and can be felt inside the vagina.  It is effective in reducing bleeding and preventing pregnancy for up to five years.  This device is different than other intrauterine devices (which are often coated with copper and can cause heavier menstrual bleeding and used for contraception only).  MIRENA reduces menstrual blood loss by as much as 97% after a year of use.  The most bothersome side effect is spotting during the first three months after insertion; by six month, the majority of women had no bleeding or infrequent light bleeding.  The progesterone releasing IUC is the most effective medical treatment for menorrhagia.  It is relatively inexpensive, and helps about 60 percent of women to avoid surgical treatments for menorrhagia.

 

Implant

A single-rod progestin implant (Implanon®) can be inserted under the skin in the upper arm.  It prevents pregnancy and can help control bleeding for up to three years.  However, the implant can be removed sooner if pregnancy is desired.  Insertion and removal can be done as an outpatient.  It is effective within 24 hours of insertion.  Irregular bleeding is the most bothersome side effect.  Fertility returns rapidly after the removal of the rod.

Non-steroidal anti-inflammatory drugs (NSAIDs) such as Brufen and Ponstan can help relieve the pain of menstrual cramping and reduce blood flow.  NSAIDs are relatively inexpensive, have few side effects and only need to be taken during a period.  However, prolonged use can cause stomach irritation and in some cases gastric hemorrhage.

 

Gonadotropin-Releasing Hormone (GnRH) Agonists

GnRH agonists may be used to temporarily control bleeding in women who are waiting to have surgical treatment.  Gonadotropin releasing hormone (GnRH) agonists (i.e. nafarelin, leuprolide and goserelin) work by turning off ovarian production of estrogen, thereby causing a temporary menopause.  The lack of estrogen causing the lining of the uterus to shrink and reduce bleeding and pain in over 80% of patients.  These can also help shrink the fibroids temporarily.  The drugs may be given as a nasal spray, implant or an injection.  The GnRH agonist is usually given for 6 months as there is risk of bone thinning if taken for longer periods.  Side effects include:

  • Headaches - 20% of omen, especially in patients with a history of migraines.
  • Signs and symptoms of menopause - lack of menstrual bleeding, hot flashes, vaginal dryness, decreased libido, insomnia and loss of bone density (on average 2-7% loss)

Many of these side effects can be minimized by giving estrogen or a bone strengthening  drug along with the GnRH agonist.  This treatment is not a permanent solution because heavy bleeding usually resumes when the drug is stopped.

 

Antifibrinolytic Agents

Drugs like tranexamic acid (Cyklokapron) and aminocaproic acid only need to be taken on the days of heavy bleeding, they do not interfere with fertility and since they act within 2-3 hours of administration, they can also be used for acute control of bleeding.  However, some women experience side effects when they take these medications.  Side effects include:

  • Stomach Problems
  • Leg Cramps
  • Dizziness
  • Headaches

Very rarely, the drug can cause thromboembolic events with serious consequences.

 

Danazol

Danazol is a medications that increases the level of androgens (male type hormone) and decreases the level of estrogen. This temporarily stops menstrual periods by inhibiting ovulation and ovarian production of estrogen by shrinking the endometrium. The medication is only taking orally 200 - 400 mg two to four times a day for 6 months or more. There is a high incidence of side effects including:

  • Weight Gain
  • Edema
  • Decreased Breast Size
  • Acne
  • Oily Skin
  • Hirsutism (male pattern hair growth)
  • Deepening of the Voice
  • Headaches
  • Hot Flashes
  • Changes in Libido
  • Mood Changes

All of these changes are reversible, except for voice changes.  Danazol is contraindicated in women with liver, kidney and heart disease.  Women who could become pregnant are advised to use a non hormonal form of birth control (i.e. condoms) when on Danazol as there is a risk of birth defects if Danazol is taken during pregnancy.

 

Surgical Treatment

Surgical removal of lesions such as polyps or fibroids can improve the menorrhagia. Fibroids may also be treated by cutting off their blood supply. This procedure is called uterine artery embolization and is preformed under radiological guidance.

 

Common Surgical Treatments for Menorrhagia

Endometrial Ablation:

this procedure involves destroying or removing the lining of the uterus.  There are several methods of endometrial ablation, all of which use an instrument that is inserted through the cervix and into the uterine cavity.  The procedure is usually done in a day surgery under mild general anaesthesia.  The most common postoperative sides effects are:

  • Cramping
  • Vaginal Discharge
  • Nausea

The discharge usually clears in 1-2 weeks.  Uterine cramping may persist for 24 to 72 hours.  Most women can resume their normal activities in 1-2 days after surgery.  Endometrial ablation reduces and often eliminates menstrual blood flow in women with menorrhagia.  However, it is not an option for women who may want to become pregnant in the future because the damage done to the endometrium often prevents pregnancy. 5-20% of women who had this procedure have had a second endometrial ablation to control uterine bleeding within 3-5 years of the initial procedure.  In addition, 9-15% undergo a hysterectomy for persistent or new uterine symptoms.

Hysterectomy:

A hysterectomy is a surgical removal of the uterus.  This is a permanent and complete treatment of menorrhagia since the source of the bleeding (the uterus) is completely removed.  However, a hysterectomy is a major surgical procedure that has more complications and a longer recovery period than an endometrial ablation.  A hysterectomy could be performed via a vaginal or abdominal route.

Uterine Artery Embolisation:

Uterine artery embolisation (UAE) is a procedure preformed under radiological guidance where the blood supply to the uterus (uterine arteries) is blocked.  It will require admission to the hospital for a few days as there could be significant pain issues after the procedure.  The procedure is used for treating large fibroids and  causes shrinkage of fibroids.  There are some safety issues concerning the procedure, particularly a risk of infection.  UAE is relatively contra-indicated in  women  desiring future pregnancy.

 

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