Menorrhagia

In a normal menstrual cycle, the average woman loses a total of 30-40 ml of blood over three to seven days. Heavy or prolonged menstrual bleeding is known as menorrhagia.

Research criteria defines this narrowly as a monthly menstrual blood loss in excess of 80 ml. A more practical definition may be that of menstrual loss that is greater than the woman feels she can reasonably manage. The National Institute for Health and Clinical Excellence (NICE) in the UK defines heavy menstrual loss as excessive blood loss that interferes with a woman’s physical, social, emotional and/or quality of life.

Menorrhagia is a common problem in clinical practice that can have adverse effects on the quality of life for many women.

Signs and symptoms

You may be experiencing menorrhagia if you have the following:

• Soaking through more than four to five pads/tampons per day
• Bleeding associated with large clots or overflow (staining of underwear or clothes)
• Needing to use double sanitary protection to control the flow
• Having to wake up at night to change sanitary protection
• Bleeding that lasts longer than a week
• Restriction of activities due to heavy flow
• Symptoms of anaemia (low blood count) such as being easily tired out, experiencing giddiness or shortness of breath with exertion

Causes of menorrhagia include :

• Dysfunctional uterine bleeding (excessive bleeding with no identifiable cause): 20-40 percent.
• Anovulatory cycles (more common at extremes of reproductive age): 20 percent.
  • This means that the ovaries do not release the egg at each cycle. This is due to hormonal imbalance.
  • In adolescents, the most common cause is an immature hypothalamus-pituitary-ovarian axis. (i.e. the chemical signalling process between the brain and the ovaries).
  • In perimenopausal women, it can be due to the depletion of ovarian function.
• Organic causes. Fibroids, endometrial polyps, adenomyosis, endometritis, pelvic inflammatory disease.
• Endometrial hyperplasia and carcinoma. This is a consideration especially in patients above 40 years old or with risk factors such as polycystic ovarian syndrome, obesity, nulliparity, early menarche, diabetes mellitus, excessive oestrogen (female hormones) either produced by the body or supplemented externally.
• Systemic disease. Including hypothyroidism, liver or kidney failure and bleeding disorders.

During consultation, your doctor will ask questions and perform an examination to try to determine the cause of the heavy menstrual bleeding.

Important information that you may provide to the doctor during the consultation include:

1. Other associated menstrual problems – pre-menstrual syndrome, inter-menstrual bleeding, post-coital bleeding, dyspareunia and pelvic pain
2. Fertility wishes
3. Whether you have symptoms of anaemia
4. Effect on your quality of life, including any time off work
5. Past medical problems, including clotting disorders, thyroid status and gynaecological history
6. Easy bruisability or bleeding gums
7. Your recent PAP smear, gynaecology history
8. Any family history of cancer

Clinical examination will be undertaken to assess for any anaemia and also to rule out potential organic causes of menorrhagia. This usually includes a pelvic examination.

Tests that may be carried out include:

• Urine pregnancy test to rule out pregnancy
• It is a good opportunity to have a PAP smear undertaken if not done recently
• Ultrasound (ideally trans-vaginal) is the first-line diagnostic tool for identifying abnormalities such as fibroids and polyps. The thickness of the lining of the womb can be seen on ultrasound.
• Endometrial sampling may be offered to test the cells in the lining of the womb, especially if there is a risk of cancer (determined by the above). This may be done in the clinic, or as a day surgery procedure called dilatation and curettage combined with the use of a small telescope to look at the inside of the womb, known as hysteroscopy. This procedure will also need to be considered in women who have not responded to medical treatment for menorrhagia.

A full blood picture will give an estimation of the degree of anaemia (low blood count). Other blood tests such as thyroid function tests and bleeding disorder testing may be performed if your doctor suspects a disorder.

The important conditions to rule out first include pregnancy, endometrial hyperplasia (abnormal thickening of the lining of the womb) and endometrial carcinoma.

If there are organic causes of menorrhagia, such as fibroids or adenomyosis, treatment options can be offered based on your wishes and fertility concerns.

If there is suspected chronic endometritis (risk factors include recent childbirth or intrauterine procedure), this can often be treated with a course of antibiotics.

If you are found to be anaemic, iron supplementation is usually recommended.

The general considerations guiding the choice of initial treatment are:

• Reason and severity of bleeding
• Associated symptoms (e.g. pelvic pain, infertility)
• Fertility – Contraceptive needs or plans for future pregnancy
• Contraindications to hormonal or other medications
• Medical comorbidities
• Restriction of activities due to heavy flow
• Patient preferences regarding medical versus surgical and shortterm versus long-term therapies

In the absence of any structural or histological abnormalities, or fibroids more than 3 cm causing distortion of uterine cavity, the recommendations for treatment are:

First line:

1. Levonorgestrel intrauterine system (LNG-IUD) - Mirena

• This is a hormone-releasing intrauterine device which can last for five years. Studies have shown this to be more effective than other medical treatments.
• This option reduces blood loss by up to 94 percent. Some women experience an increase in irregular or heavy bleeding during the first three months after placement of the LNG-IUD. After three months, the most common bleeding pattern in previously menorrhagic women is spotting, and after six months, the majority of patients have amenorrhoea (absence of menstruation) or oligomenorrhoea (infrequent menstruation).
• Other benefits include reduction in dysmenorrhoea (painful menses) in patients with endometriosis or adenomyosis, reduction in endometrial cancer risk, as well as birth control.

Second line:

1. Tranexamic acid

• This medication works by stabilising a protein that helps blood to clot. It can reduce flow by up to 50 percent and is taken three or four times a day, for a maximum of three to four days during the period.
• This medication is non-hormonal in nature and will not affect fertility.

2. Non-steroidal anti-inflammatory drugs (NSAIDs)

• Medications in this class of drug include ponstan (mefenamic acid), naproxen (synflex), ibuprofen.
• NSAIDs work by reducing your body’s production of prostaglandin from the womb, which is linked to heavy periods. NSAIDs are also painkillers. They do not affect your fertility and are taken during your period.
• The reduction in blood loss is by 33-55 percent.
• Side effects include nausea, vomiting and diarrhoea.

3. Combined oral contraceptive pill (COCP)

• These contain two hormones – oestrogen and progestogen.
• There is a reduction of menstrual blood loss by around 40 percent.
• Other benefits include birth control, regulation of cycle, improvement in pre-menstrual symptoms, reduction in painful menses and protection of the ovaries and endometrium (womb lining) against cancer.

Third line:

1. Norethisterone

• This is a type of man-made progestogen (one of the female sex hormones).
• This is taken, from day 5 to 26 of the menstrual cycle.
• It is not an effective form of birth control and may have side effects such as weight gain, breast tenderness and acne.
• It is usually used for short-term treatment of menorrhagia.

2. Progestogen injection

• A type of progestogen called medroxyprogesterone acetate is also available as an injection and is sometimes used to treat menorrhagia.
• This is useful for contraception and is usually given threemonthly. This treatment is usually limited to two years due to risk of bone loss with prolonged use.
• Side effects include weight gain, irregular bleeding, occasional delayed return to fertility after stopping the medication.

3. GnRH analogue

• This is hormone medication given to mimic menopause (it lowers the female hormones in the body).
• It is not a routine treatment but may be used to shrink fibroids before operation and control bleeding to allow anaemia to recover before surgery.

This may be considered also if you are close to menopause and other treatments are not working or contraindicated.

Surgical options

The choice of treatment will depend on both the uterine size and the patient’s desire to retain her uterus.

1. Endometrial ablation

• This option can be considered if the uterus size is not too large or distorted by fibroids. You will also need to use a reliable form of contraception after the treatment as pregnancy is contraindicated due to the high risk of problems.
• This involves removing the full thickness of the lining of the womb.

2. Uterine artery embolisation

• This involves injecting small plastic beads to block the arteries supplying the womb.
• This is usually offered to women who have heavy menses due to large fibroids, as blocking the blood supply will cause the fibroids to shrink with time.

3. Hysterectomy (removal of the womb)

• This option can be considered when other options have been exhausted and the patient chooses not to retain her fertility. * If menorrhagia is due to fibroids, surgical treatment may include myomectomy (surgery to remove fibroids), rather than hysterectomy.