Heavy Menstrual Bleeding – Causes, Symptoms, Treatment

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Heavy Menstrual Bleeding/Menorrhagia is prolonged and excessively heavy menstrual bleeding at regular menstrual cycle intervals. Although several factors (e.g. anatomical defects or growths in the womb, blood component abnormality, or hormonal imbalance) may be implicated, the cause of the abnormal uterine bleeding is often unknown.

Menorrhagia is menstrual bleeding that lasts more than 7 days. It can also be bleeding that is very heavy. How do you know if you have heavy bleeding? If you need to change your tampon or pad after less than 2 hours or you pass clots the size of a quarter or larger, that is heavy bleeding. If you have this type of bleeding, you should see a doctor.

Menorrhagia (also known as heavy menstrual bleeding) is defined as heavy, but regular, menstrual bleeding. Menorrhagia menstruation at the regular cyclical interval with excessive flow and duration; clinically, blood loss is in excess of 80 ml per cycle; or menses lasts longer than 7 days8

Types of Menorrhagia

  • Idiopathic ovulatory menorrhagia – is regular heavy bleeding in the absence of recognisable pelvic pathology or a general bleeding disorder.
  • Objective menorrhagia – is taken to be a total menstrual blood loss of 80 mL or more in each menstruation. It is difficult to incorporate the objective measurement of menstrual blood loss into everyday practice. Subjectively, menorrhagia may be defined as a complaint of regular excessive menstrual blood loss that interferes with the woman’s physical, emotional, social, and material quality of life, and that can occur alone or in combination with other symptoms.
  • Metrorrhagia – intermenstrual bleeding occurring at any time between menstrual periods17p1355
  • Hypomenorrhea – (cryptomenorrhea)-unusually light menstrual flow, sometimes only spotting, or a deficient amount of menstrual flow17p1052
  • Menometrorrhagia – bleeding that occurs at irregular intervals or bleeding during and between menstrual periods in which amount and duration of bleeding may also vary17p1339
  • Polymenorrhea – menstrual periods occurring with abnormal frequency17p1726
  • Oligomenorrhea – periods that occur more than 35 days apart or scanty or infrequent menstrual flow17p1516

Dysfunctional menses – abnormal uterine bleeding without any obvious structural or systemic abnormality8,19

Causes of Heavy Menstrual Bleeding

  • Hormone imbalance – In a normal menstrual cycle, a balance between the hormones estrogen and progesterone regulates the buildup of the lining of the uterus (endometrium), which is shed during menstruation. If a hormone imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding.
  • Dysfunction of the ovaries – If your ovaries don’t release an egg (ovulate) during a menstrual cycle (anovulation), your body doesn’t produce the hormone progesterone, as it would during a normal menstrual cycle. This leads to hormone imbalance and may result in menorrhagia.
  • Uterine fibroids – These noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.
  • Polyps – Small, benign growths on the lining of the uterus (uterine polyps) may cause heavy or prolonged menstrual bleeding.
  • Adenomyosis – This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and painful periods.
  • Intrauterine device (IUD) – Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for birth control. Your doctor will help you plan for alternative management options.
  • Pregnancy complications – A single, heavy, late period may be due to a miscarriage. Another cause of heavy bleeding during pregnancy includes an unusual location of the placenta, such as a low-lying placenta or placenta previa.
  • Cancer – Uterine cancer and cervical cancer can cause excessive menstrual bleeding, especially if you are postmenopausal or have had an abnormal Pap test in the past.
  • Inherited bleeding disorders – Some bleeding disorders — such as von Willebrand’s disease, a condition in which an important blood-clotting factor is deficient or impaired — can cause abnormal menstrual bleeding.
  • Medications – Certain medications, including anti-inflammatory medications, hormonal medications such as estrogen and progestins, and anticoagulants such as warfarin (Coumadin, Jantoven) or enoxaparin (Lovenox), can contribute to heavy or prolonged menstrual bleeding.
  • Other medical conditions – A number of other medical conditions, including liver or kidney disease, may be associated with menorrhagia.

Others Cause May Consideration

Excessive menses but normal cycle – Painless

  • Fibroids (leiomyoma) — fibroids in the wall of the uterus cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrial surface area.
  • Coagulation defects (rare) — with the shedding of an endometrial lining’s blood vessels, a normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities
  • Endometrial cancer (cancer of the uterine lining) — bleeding can also be irregular, in between periods, or after menopause (post-menopausal bleeding or PMB)
  • Endometrial polyp
  • Omega 6 and prostaglandins – HMB is associated with increased omega-6 AA in uterine tissues.[rx] The endometrium of women with HMB have higher levels of prostaglandin (E2, F2alpha, and others) when compared with women with normal menses.[rx] It is thought that prostaglandins are a by-product of omega 6 build-up.[rx]

Painful (ie associated with dysmenorrhea)

  • Pelvic inflammatory disease
  • Endometriosis – an extension of the endometrial tissue outside of the uterus tries to shed causing painful and abnormal bleeds
  • Adenomyosis – an extension of the endometrial tissue into the wall of the uterus tries to shed causing painful and abnormal bleeds
  • Pregnancy related complication (i.e. miscarriage)
  • Short cycle (less than 21 days) but normal menses.
  • Short cycle and excessive menses due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumors.
  • Polycystic ovary syndrome.[rx]
  • Systemic causes: thyroid disease, excessive emotional/physical stress.[rx]
  • Sexually transmitted infection.[rx]
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Hormonal Abnormalities

  • Luteal phase defects
  • Stress
  • Exogenous hormones
  • Ovarian Cysts

Mechanical Abnormalities

  • Uterine Polyps
  • Uterine Fibroids
  • Intrauterine devices
  • Atopic pregnancy
  • Pregnancy

Clotting Abnormalities

  • Drug-induced hemorrhage
  • Dysproteinemias
  • Disseminated intravascular coagulation
  • Severe hepatic disease
  • Primary fibrinolysis

Symptoms of Heavy Menstrual Bleeding

You may be experiencing menorrhagia if you have the following:
  • Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
  • Needing to use double sanitary protection to control your menstrual flow
  • Needing to wake up to change sanitary protection during the night
  • Bleeding for longer than a week
  • Passing blood clots larger than a quarter
  • Restricting daily activities due to heavy menstrual flow
  • Symptoms of anemia, such as tiredness, fatigue, or shortness of breath
  • Menstrual flow that soaks through one or more sanitary pads every hour
  • The need to use double sanitary protection to control your menstrual flow
  • The menstrual period lasts more than seven days
  • Menstrual flow that includes large blood clots
  • Excessive and prolonged menses may lead to anemia,
  • Pallor
  • Tiredness
  • Fatigue
  • Shortness of breath

According to the CDC

You might have menorrhagia if you:

  • Have a menstrual flow that soaks through one or more pads or tampons every hour for several hours in a row.
  • Need to double up on pads to control your menstrual flow.
  • Need to change pads or tampons during the night.
  • Have menstrual periods lasting more than 7 days.
  • Have a menstrual flow with blood clots the size of a quarter or larger.
  • Have a heavy menstrual flow that keeps you from doing the things you would do normally.
  • Have constant pain in the lower part of the stomach during your periods.
  • Are tired, lack energy, or are short of breath.


Diagnosis of Heavy Menstrual Bleeding

Menorrhagia is diagnosed by your doctor through a series of questions about your medical history and menstrual cycles. Usually for women with menorrhagia bleeding lasts for more than 7 days and more blood is lost (80 milliliters compared to 60 milliliters).

Your doctor may ask for information about:

  • Your age when you got your first period
  • Length of your menstrual cycle
  • Number of days your period lasts
  • Number of days your period is heavy
  • Quality of life during your period
  • Family members with a history of heavy menstrual bleeding
  • The stress you are facing
  • Weight problems
  • Current medications

Imaging and Lab Test

  • Full blood count – Hemoglobin concentration is a surrogate assessment for excessive menstrual loss. Other indices within the full blood count may more accurately assess iron state. Full blood count should be undertaken in all women presenting with menorrhagia
  • A pregnancy test – should always be performed in women of childbearing age, regardless of their history of sexual activity. In stable non-pregnant women with menorrhagia, there is no indication for other tests in the emergency department setting; however, outpatient workup can be extensive. Outpatient studies often consist of tests to assess for anemia and blood dyscrasias (ferritin, coagulation studies, complete blood count, and bleeding studies), tests to assess for thyroid disease (TSH and free T4), tests to assess for liver disease, and even advanced procedures (hysteroscopy) to look for anatomical causes of bleeding.
  • Coagulation screen – Tests for coagulopathies such as von Willebrand’s disease should only be undertaken when specifically indicated by the history
  • Thyroid function tests – There is little evidence to link hypothyroidism with the excessive menstrual loss and no evidence for hyperthyroidism to be a cause. Thyroid function tests should not be routinely undertaken
  • Other endocrine investigations – No significant endocrine abnormality has been detected in menorrhagia., There is no indication for any endocrine investigation
  • Pelvic ultrasound – Routine pelvic ultrasound has little place in evaluating the primary complaint of excessive menstrual loss. It is of value in evaluating other pelvic disorders discovered during a clinical examination
  • Endometrial sampling – As part of the initial assessment, there is no place for endometrial sampling. Sampling should be combined with further assessment of the endometrial cavity, for example, hysteroscopy, in selected cases only. Selected cases would include women over 40, women complaining of intermenstrual bleeding, and after a failed trial of medical treatment
  • Pap test – In this test, cells from your cervix are collected and tested for infection, inflammation or changes that may be cancerous or may lead to cancer.
  • Endometrial biopsy. Tissue samples are taken from the inside lining of your uterus or “endometrium” to find out if you have cancer or other abnormal cells. You might feel as if you were having a bad menstrual cramp while this test is being done. But, it does not take long, and the pain usually goes away when the test ends.
  • Sonohysterography – During this test, a fluid is injected through a tube into your uterus by way of your vagina and cervix. Your doctor then uses an ultrasound to look for problems in the lining of your uterus.
  • Hysteroscopy – This exam involves inserting a thin, lighted instrument through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus.
  • Electric hysterogram – This ultrasound scan is done after fluid is injected through a tube into the uterus by way of your vagina and cervix. This lets your doctor look for problems in the lining of your uterus. Mild to moderate cramping or pressure can be felt during this procedure.
  • Hysteroscopy – This is a procedure to look at the inside of the uterus using a tiny tool to see if you have fibroids, polyps, or other problems that might be causing bleeding. You might be given drugs to put you to sleep (this is known as “general anesthesia) or drugs simply to numb the area being looked at (this is called “local anesthesia”).
  • Dilation and Curettage (D&C) – This is a procedure (or test) that can be used to find and treat the cause of bleeding. During a D&C, the inside lining of your uterus is scraped and looked at to see what might be causing the bleeding. A D&C is a simple procedure. Most often it is done in an operating room, but you will not have to stay in the hospital afterward. You might be given drugs to make you sleep during the procedure, or you might be given something that will numb only the area to be worked on.
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Treatment of Heavy Menstrual Bleeding

Medications

These have been ranked by the UK’s National Institute for Health and Clinical Excellence:[rx]

  • First-line
    • An intrauterine device with progesterone
  • Second Line
    • Tranexamic acid an antifibrinolytic agent
    • Nonsteroidal anti-inflammatory drugs (NSAIDs).
    • Combined oral contraceptive pills to prevent the proliferation of the endometrium
  • Third line
    • An oral progestogen (e.g. norethisterone), to prevent the proliferation of the endometrium
    • An injected progestogen (e.g. Depo Provera)
  • Other options
    • Gonadotropin-releasing hormone agonist
Sample Treatment Plan for Chronic Recurring Menorrhagia
  • Bioflavonoids, 1000 mg twice per day
  • Vitamin A 60,000IU per day
  • Chaste tree (standardized extract) 175 mg per day; or ½–1 tsp daily
  • Combination herbal product using astringents and uterine tonics
  • Consider natural progesterone cream, ¼ to ½ tsp, 12–21 days/month
  • Oral micronized progesterone: 200–300 mg per day for 7–12 days followed by a cyclic hormone product for 21 days on and 7 days off

Drug Therapy

  • Iron supplements – To get more iron into your blood to help it carry oxygen if you show signs of anemia.
  • Ibuprofen (Advil) – To help reduce pain, menstrual cramps, and the amount of bleeding. In some women, NSAIDs can increase the risk of bleeding.
  • Intrauterine contraception (IUC) – To help make periods more regular and reduce the amount of bleeding through drug-releasing devices placed into the uterus.
  • Desmopressin Nasal Spray Stimate – To stop bleeding in people who have certain bleeding disorders, such as von Willebrand disease and mild hemophilia, by releasing a clotting protein or “factor”, stored in the lining of the blood vessels that help the blood to clot and temporarily increasing the level of these proteins in the blood.
  • Antifibrinolytic medicines (aminocaproic acid) – To reduce the amount of bleeding by stopping a clot from breaking down once it has formed.
  • Prostaglandin inhibitors – These are nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin or ibuprofen. They help reduce cramping and the amount you bleed.
  • Anti-inflammatory medication like NSAIDs – may also be used. NSAIDs are the first-line medications in ovulatory heavy menstrual bleeding, resulting in an average reduction of 20-46% in menstrual blood flow. NSAIDs may be more effective than placebo in terms of reducing blood loss increasing women’s subjective perception of improvement, they may be less effective than tranexamic acid. It is uncertain if there is any difference between NSAIDs and tranexamic acid in terms of women’s subjective perception of bleeding.[rx] For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.[rx]
  • Tranexamic acid – reduces menstrual blood loss by about half, and nonsteroidal anti-inflammatory drugs reduce it by about a third. Tranexamic acid tablets may also reduce loss by up to 50%.[rx] This may be combined with hormonal medication previously mentioned.[rx]NICE guidelines say that for women (with HMB and no identified pathology or fibroids less than 3 cm in diameter) who do not wish to have the pharmacological treatment and who do not want to conserve their fertility, surgical options could be considered as a first-line treatment option. And options are hysterectomy and second-generation endometrial ablation. With hysterectomy more effective than second-generation endometrial ablation.[rx]
  • Vitamin K and chlorophyll – Although bleeding time and prothrombin levels in women with menorrhagia are typically normal, the use of vitamin K (historically in the form of crude preparations of chlorophyll) has clinical and limited research support.”
  • Hormonal therapy – for menorrhagia has been progestogens given during the luteal phase of the cycle. Such treatments are ineffective. Despite this, they remain the first choice of many general practitioners and gynecologists., Progestogens are effective when given for 21 days in each cycle, but the side effects may be such that patients choose not to continue with treatment. Although progestogens have a contraceptive effect, their use in this way may not be the best choice when contraception is required by the patient.
  • The combined contraceptive pill – is both an effective contraceptive and treatment of menorrhagia compared with other medical treatments. This statement, however, cannot be expanded upon because good-quality data are lacking, and the use of the contraceptive pill in this area has been insufficiently studied. Nevertheless, like cyclical progestogens, combined oral contraceptives are useful for anovulatory bleeding because they impose a cycle.
  • Vitamin B Complex – There may be a correlation between a deficiency of vitamin B and menorrhagia. With Vitamin B complex deficiencies, the liver looses it ability to inactivate estrogen. Some cases of menorrhagia are due to excess estrogen’s effect on the endometrium. The vitamin B complex may help to normalize estrogen metabolism.
  • Vitamin C and Bioflavonoids – Vitamin C, along with bioflavonoids, help reduce heavy bleeding by making the capillaries stronger and preventing them from becoming fragile. In one small study with 18 women who had heavy menstrual bleeding, bleeding improved in 16 out of the 18 patients when the women took Vitamin C and bioflavonoids. In addition, vitamin C can also help women who have suffered from iron deficiency from menorrhagia by increasing iron absorbency.
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Specific hormonal contraceptives for the treatment of HMB

Estrogen: EEProgestinComments
Combined hormonal contraceptives
Combined oral contraceptive pillsPackaged as 21 d of active pills or 21 d of active pills + 7 d of placebo pills
20 μg EE1 mg norethindroneAvailable in an extended cycle regimen with 24 d of active pills + 4 d of placebo
30 μg EE1.5 mg norethindrone
35 μg EE1 mg norethindrone
20 μg EE0.1 mg levonorgestrel
20 μg EE90 μg levonorgestrelMarketed as a continuous regimen
30 μg EE1.5 mg levonorgestrelAvailable in an extended cycle regimen with 84 d of active pills + 7 d of placebo or 10 μg of EE
Patch20 μg EE daily150 μg of norelgestromin dailyApplied weekly for 3 wk out of 4
Ring15 μg EE daily120 mcg of etonogestrel dailyWorn 3 wk out of 4
Progestin-only contraceptives
Pills0.35 mg norethindroneDaily
Intramuscular injection150 mg DMPAEvery 3 mo
Subcutaneous injection104 mg DMPAEvery 3 mo
Subcutaneous implant68 mg etonogestrelSlowly released over ≥3 y; ∼60 μg daily after 3 mo, which slowly decreases to 30 μg daily at the end of 2 y
Intrauterine device52 mg levonorgestrelRelease rate of 20 μg daily, FDA-approved for 5 y of use
13.5 mg levonorgestrelRelease rate of 14 μg daily, FDA approved for 3 y of use

Surgery

  • Dilation and curettage (D&C) – is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if spontaneous abortion is incomplete[rx] In this procedure, your doctor opens (dilates) your cervix and then scrapes or suctions tissue from the lining of your uterus to reduce menstrual bleeding. Although this procedure is common and often treats acute or active bleeding successfully, you may need additional D&C procedures if menorrhagia recurs.
  • Endometrial ablation – is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy.[rx] For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply. During uterine artery embolization, the surgeon passes a catheter through the large artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with materials that decrease blood flow to the fibroid.
  • Uterine artery embolization (UAE) – The rate of serious complications is comparable to that of myomectomy or hysterectomy; however, UAE presents an increased risk of minor complications and requiring surgery within two to five years.[rx]
  • Hysteroscopic myomectomy – to remove fibroids over 3 cm in diameter
  • Focused ultrasound surgery – Similar to uterine artery embolization, focused ultrasound surgery treats bleeding caused by fibroids by shrinking the fibroids. This procedure uses ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure.
  • Myomectomy – This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
  • Endometrial ablation – This procedure involves destroying (ablating) the lining of your uterus (endometrium). The procedure uses a laser, radiofrequency or heat applied to the endometrium to destroy the tissue. After endometrial ablation, most women have much lighter periods. Pregnancy after endometrial ablation has many associated complications. If you have endometrial ablation, the use of reliable or permanent contraception until menopause is recommended.
  • Endometrial resection – This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding. Pregnancy isn’t recommended after this procedure.
  • Hysterectomy –  Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. A hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.


Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down the questions you want to be answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also, know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

References

  1. https://www.ncbi.nlm.nih.gov/books/NBK279294/
  2. https://www.ncbi.nlm.nih.gov/books/NBK470230/
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907973/
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4574688/
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2077876/
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070839/
  7. https://en.wikipedia.org/wiki/Heavy_menstrual_bleeding
  8. https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
  9. https://www.nhs.uk/conditions/heavy-periods/treatment/
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