Gynaecology - Heavy Periods (Menorrhagia)

Heavy periods are common and the cause is not sinister in most cases. Heavy periods can be unbearable, causing more than the usual inconvenience of menstruation. At times they can even lead to social embarrassment. With a reduction in family size and less breastfeeding and effective modification of contraception, a woman can now expect to see a nine times increase in the number of menstrual cycles in her lifetime, compared to her great-grandmother.
This leaflet is designed to give general information about heavy periods and treatment options. You need to discuss with your doctor what treatment would be best for you.

What are normal and heavy periods?

About one in three women describe their periods as ‘heavy’. However, it is often difficult to know if your periods are normal or heavy compared to other women. Some women who feel they have heavy periods actually have an average blood loss. Some women who feel they have normal periods actually have a heavy blood loss. Most of the blood loss (about 90%) usually occurs in the first three days, with either normal or heavy periods.
 
The strict medical definition is:

●    A ‘normal’ period is a total blood loss between 20 and 60 ml. (4-12 teaspoonfuls.) Bleeding can last up to eight days, but bleeding for five days is average
●    A ‘heavy’ period is a total blood loss of 80 ml or more. This is about half a teacupful or more. Menorrhagia means recurring heavy periods However, it is difficult to measure the amount of blood that you lose during a period

For practical purposes, a period is heavy if it causes one or more of the following:

●    Flooding through to clothes or bedding
●    Needing frequent changes of sanitary towels (every 2 hours or more)
●    Needing double sanitary protection (tampons and towels)
●    Passing large blood clots stopping you doing normal activities such as going out, working, or shopping

What causes heavy periods?

The exact cause is not known in most cases - this is called ‘dysfunctional uterine bleeding’. In this condition the uterus (womb) and ovaries are normal. It is not a hormone problem. When ovulation is normal, the periods are regular and at the extremes of reproductive life, ovulation may not occur regularly and irregular heavy periods can occur. A chemical called prostaglandin may play a part. The amount of prostaglandin in the lining of the uterus is usually higher than normal in women with heavy periods. The high level of prostaglandin affects blood clotting and bleeding then takes longer than normal to stop.

Other causes

These are less common. They include the following:

Fibroids. These are benign (non-cancerous) growths in the muscle of the uterus. They often cause no problems, but sometimes cause symptoms such as heavy periods.

Other conditions of the uterus, such as infections or polyps, may lead to heavy periods. A tumour of the uterus is an uncommon cause. This occurs in a small number of women, usually over the age of 40.

Hormone problems. Periods can be irregular and sometimes heavy if you do not ovulate every month. An underactive thyroid gland may cause heavy periods.

The Copper Coil typically used for contraception sometimes causes heavy periods. A special hormone releasing coil can actually treat heavy periods.

Warfarin or similar medicines interfere with blood clotting. If you take one of these for other conditions, it may have a side effect of heavier periods.

Blood clotting disorders are rare causes of heavy bleeding and other symptoms, such as easy bruising, are also likely to be present.

Obese women are more likely to have heavy periods than women of average weight.

Some women become used to the light monthly bleeds that occur whilst on ‘the pill’. Normal periods return if you stop the pill. These may appear heavier, but are usually normal.

Are any tests needed if I have heavy periods?

An internal (vaginal) examination is done by a doctor to check on the size and feel of the uterus.

If the vaginal examination is normal (as it is in most cases), often no further tests are needed, if you are below 40 years of age.

A blood test to check for anaemia may be needed. Some women bleed so heavily that the body cannot replace the blood loss quickly enough. Anaemia may develop and cause tiredness.

The diagnosis is usually ‘dysfunctional uterine bleeding’ and treatment may be started if required. Further tests may be advised for women over 40 years. This may be if a doctor detects a large or abnormal uterus, or if you have other symptoms which may indicate an underlying problem.

For example, the following symptoms may indicate the need for further investigations if you:

●    Bleed between periods, or have irregular bleeding
●    Have bleeding or pain during, or just after, sex
●    Have pain apart from normal period pain
●    Have any change in your usual pattern of bleeding, particularly if you are over 40
●    Have symptoms suggesting a hormone problem or blood disorder

Tests may include a look into the uterus with a small magnifying telescope via the vagina (hysteroscopy). A small sample of the lining (biopsy) may be taken during this test. An ultrasound scan of the uterus may also be advised.

Keeping a menstrual diary

It may be worth keeping a diary covering a few menstrual cycles (before and after any treatment). It means making a daily record during each period. Make an entry of ‘very heavy’, ‘heavy’, ‘medium’, or ‘light’ bleeding for each day. Also, note the number of sanitary towels that you need, and the number of days of bleeding. Also, note if you have any flooding or interruption of normal activities. A diary is useful for both patient and doctor to see. It could show:

●    How bad symptoms are, and whether treatment is needed
●    If treatment is started, to assess if it is helping. Some treatments take a few menstrual cycles to work fully. If you keep a diary it helps you to remember exactly how things are going

What are the treatment options for heavy periods?

Treatment aims to reduce the amount of blood loss. The rest of this leaflet discusses treatment options for women who have regular but heavy periods with no clear cause (ovulatory dysfunctional uterine bleeding). This is the majority of cases. If there is an underlying cause, such as a fibroid or endometriosis, treatment options may be different.

Not treating

This is an option if your periods do not interfere too much with normal life. You may be reassured that there is no serious cause for your heavy periods, and you may be able to ‘live with them’. A blood test may be advised every so often to check for anaemia. Iron tablets can correct anaemia.

Tranexamic acid tablets

These reduce bleeding by almost half (40-50%) in most cases. You need to take a tablet 3-4 times a day, for 3-4 days during each period. They work by reducing the breakdown of blood clots in the uterus. In effect they ‘strengthen’ the blood clots in the uterus lining which leads to less bleeding. They do not ease period pain. Side effects are usually minor, but may include an upset stomach. The heaviness of the bleeding is eased, but the number of days of bleeding may not be reduced.

Anti-inflammatory medicines

These are popular as they also ease period pain. Most are available only on prescription but you can buy ibuprofen from pharmacies. These medicines reduce the blood loss by about a third (20-50%) in most cases. You need to take the tablets during the menstrual period. They work by reducing the high level of prostaglandin in the uterus lining, which seems to contribute to heavy periods. The heaviness of the bleeding and the pain are eased, but the number of days the period lasts may not be reduced. Side effects may include an upset stomach. If you have a history of a duodenal or stomach ulcer, or asthma, you should only take these medicines on a doctor’s advice.

The Contraceptive Pill

This reduces bleeding by about a third in most women - sometimes more. It often helps with period pain too. It is a popular treatment with women who also want contraception. You can take this in addition to either of the above two treatments. This choice of treatment is not suitable for every woman and requires careful accessment by your doctor.

Levonorgestrel Intrauterine System (LNG-IUS) (Mirena)

This is similar to an intrauterine device (IUD or ‘coil’). It is inserted into the uterus and slowly releases a small amount of a progestogen hormone called levonorgestrel. Each system lasts five years. The amount of hormone released each day is tiny but sufficient to work inside the uterus. In most women, bleeding becomes either very light or stops altogether within 3-6 months. However, the light periods may become irregular. It is also a very effective contraceptive with fewer complications than other intrauterine devices. It works mainly by making the lining of the uterus very thin.

Long acting progestogen contraceptives

The contraceptive injection and the contraceptive implant tend to reduce heavy periods. For example, up to half of women on the contraceptive injection have no periods after a year. They are not given as a treatment just for heavy periods. However, if you require contraception then one of these may be a good choice for you.

Surgical treatment

This is an option if the above treatments do not help or are unsuitable.

●    Endometrial ablation or resection. An instrument is passed into the uterus via the vagina. The aim is to remove or destroy as much of the uterus lining as possible. There are various methods available which your clinician will be able to discuss with you. It is effective in 60 - 80% of patients. You will still need contraception. This treatment is unsuitable for women who want to get pregnant in the future
●    Hysterectomy is the traditional operation. This totally removes the uterus. It is 100% effective at curing heavy periods. Some other advantages are that you no longer need contraception, and the risk of cancer of the uterus is removed. However, as with any operation, there are risks associated with hysterectomy. Also, you need to stay in hospital for several days, and it may take many weeks to recover fully. There are risks of damage to your bowels, urinary tract and blood vessels. It is also associated with incontinence and sexual problems post-operatively. The risk of complications is 1 in 30.
●    Subtotal hysterectomy is when the cervix is left behind for any reason. There is a chance that slight cyclical (monthly) bleeding will occur

Endometrial Ablation v’s Hysterectomy

Some advantages over hysterectomy include:
●    fewer risks
●    short hospital stay
●    no scar
●    quicker recovery time

Some disadvantages over hysterectomy include:
●    you still need contraception
●    it does not cure symptoms in approximately 1 in 10 women and symptoms may return (within four years about a third of women require repeat surgery). However, this technique is being refined and may become more effective in the future