The menstrual cycle is individual to every woman. What is ‘normal’ for one may not be ‘normal’ for another. However, periods can disturb a woman’s lifestyle and cause severe anxiety. They may be notably heavy and/or prolonged (menorrhagia) or irregular. Some women may also bleed between their periods (intermenstrual bleeding) or after sexual intercourse (postcoital bleeding). These require further investigation by a qualified gynaecologist.
Menorrhagia – Heavy Menstrual Bleeding
Menorrhagia is the official medical term for periods which are abnormally heavy or prolonged. Although heavy menstrual bleeding is a common concern, most women don’t experience such severe cramping and blood loss that they can’t maintain normal activities during their period.
- Vaginal bleeding that soaks through at least sanitary pad or tampon every hour over several consecutive hours
- Needing to use double sanitary protection
- Needing to wake up during the night to change sanitary protection
- Bleeding longer than a week
- Passing large blood clots
- Restriction on daily activities due to a heavy menstrual flow
- Anaemia – feeling extremely tired or a shortness of breath
Causes of Menorrhagia
In some instances, the cause of heavy vaginal bleeding will remain unknown but there are a number of conditions which may lead to the development of menorrhagia. Nevertheless, the risk factors vary with age and whether there are any other medical conditions:
- Hormone imbalance – the build-up of the endometrium (the lining of the uterus/womb) is not sufficiently regulated by oestrogen and progesterone hormone levels. This may arise from obesity, insulin resistance, thyroid problems or polycystic ovary syndrome (PCOS);
- Anovulation – This is a dysfunction of the ovaries, namely when a woman fails to ovulate (i.e. her ovaries don’t release an egg) during her period. This means that her body doesn’t produce the progesterone hormone as it normally would during the menstrual cycle. This is typical among adolescent girls in the first year of ovulation;
- Uterine Fibroids – Uterine fibroids are benign (non-cancerous) tumours. This is typical of older reproductive woman, particularly during childbearing years;
- Uterine Polyps – these are small, benign (non-cancerous) growths on the lining of the uterus. This is typical of older reproductive woman;
- Adenomyosis – glands from the endometrium become embedded in the uterine muscle;
- Medications – medicine for anti-inflammatory complaints, hormonal issues (e.g. oestrogen and progestin) as well as anticoagulants;
- Intrauterine Device (IUD) – a common side effect of using a non-hormonal intrauterine device for birth control;
- Pregnancy Complications – A single, heavy, late period may be due to a miscarriage. Another cause of bleeding during pregnancy includes an unusual location of the placenta (i.e. low-lying placenta or placenta previa);
- Uterine and Cervical Cancer – This is especially so if a woman has an abnormal Pap smear test or is postmenopausal;
- Inherited Bleeding Disorders – for example, Von Willebrand disease. This is a condition where an important blood-clotting regulator is deficient or impaired.
Investigative Diagnosis of Menorrhagia
We conduct a number of methods to determine your diagnosis. Clinical examinations includes:
- Blood tests to evaluate for iron deficiency (anaemia) and other conditions, such as thyroid disorders or blood-clotting abnormalities;
- Pap smear test;
- Biopsy of the lining of the womb;
- Ultrasound scan to assess the uterus, the cervix and the ovaries
Based on the results of your initial tests, your doctor may recommend further testing, including a hysteroscopy. This is an examination which involves inserting a tiny camera through your vagina and cervix into your uterus. It can be done under local or general anaesthetic.
Treatment For Menorrhagia
A treatment plan needs to be based on a number of factors, including:
- The impact the condition has on a woman’s lifestyle
- A woman’s overall health and medical history
- The cause and severity of the condition
- A woman’s tolerance to specific medications, procedures and/or therapies
- The likelihood that their periods will become less heavy in time
- Future childbearing plans
Once the above have been reasonably considered, medications can be offered:
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) – these can help to reduce menstrual blood loss. NSAID’s have the additional benefit of relieving painful menstrual cramps (dysmenorrhea);
- Tranexamic Acid (Lysteda) – these can help to reduce menstrual blood loss. They only need to be taken at the time of the bleeding;
- Oral Contraceptives – Aside from providing birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding;
- Oral progesterone – the progesterone can help correct hormone imbalance
- Hormonal IUD – intrauterine devices release a type of progestin called levonorgestrel. This makes the uterine lining thin and decreases menstrual blood flow and cramping;
- Iron Supplements for those who are suffering from anaemia
If the above have been unsuccessful then your consultant may need to offer a surgical treatment. These include:
- Dilation and Curettage (D&C) – A cervix is dilated (opened) so the lining of the uterus can be scraped away. This procedure is common and successfully treats acute or active menstrual bleeding, a series of D&C procedures may be required;
- Uterine Artery Embolisation – this is used when menorrhagia is caused by a fibroid issue(s). It shrinks uterine fibroids by blocking the uterine arteries and cutting off their blood supply;
- Focused Ultrasound Surgery – shrinks fibroids with ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure;
- Myomectomy – this involves the surgical removal of uterine fibroids. Depending on their size, number and location your surgeon may choose to perform the myomectomy using open abdominal surgery with several small incisions (laparoscopically) or through the vagina and cervix (hysteroscopically);
- Endometrial ablation – this procedure involves destroying (ablating) the lining of the uterus (endometrium). This can be done with heat, a laser or radiofrequency onto the endometrium to destroy the tissue. However, getting pregnant afterwards has many associated complications. If you have endometrial ablation, the use of reliable or permanent contraception until menopause is recommended;
- Endometrial resection – an electrosurgical wire loop is used to remove the lining of the uterus although pregnancy isn’t recommended after this procedure;
- Hysterectomy— the surgical removal of the uterus and cervix. It is a permanent procedure that causes sterility and ends menstrual periods. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.
Aside from abdominal myomectomies and hysterectomies which require a hospital stay the other surgical procedures can be performed on an outpatient basis. Whilst a general anaesthetic may well be used, it’s likely that you can go home later on the same day.
Intermenstrual Bleeding (IMB)
This condition is defined as vaginal bleeding at any time during the menstrual cycle other than during normal menstruation. Unfortunately, it can be difficult to differentiate between intermenstrual bleeding and irregular periods.
Causes of IMB
- Problematic pregnancy – ectopic pregnancy and gestational trophoblastic disease;
- 1-2% spot around ovulation;
- Hormonal fluctuation;
- vaginal – cancer, vaginitis or adenosis;
- cervical – STI, cancer, polyps, ectropion or condylomata acuminata;
- uterine – fibroids, endometrial polyps, cancer, adenomyosis or endometriosis;
- oestrogen-secreting ovarian cancer
Women experiencing inter menstrual bleeding require clinical examination by a gynaecologist and a pelvic ultrasound scan. Blood tests can be requested and the treatment will depend on the cause of the symptoms. However, no specific cause for bleeding is found in about 50% of women.
Postcoital Bleeding (PCB)
This is non-menstrual bleeding that occurs immediately after sexual intercourse. It is usually caused by lesions of the cervix or the vagina. It is important that every woman who notices persistent bleeding after intercourse needs to be assessed by a gynaecologist.
Causes of PCB
- Cervical Ectropin, especially amongst women taking the combined oral contraceptive pill (COCP)
- cervical or vaginal cancer
- Cervical or endometrial polyps
It is worth noting that IMB and PCB are both considered to be symptoms, rather than a diagnosis in itself. Further assessments should, therefore, be carried out by your consultant as they are often linked with the onset of cancer. Genital tract malignancy, whilst an uncommon cause of bleeding, particularly among young women, it must still be considered in all patients.
It has been estimated that around 1/3 of women who exhibit menstrual problems will have IMB or PCB in addition to heavy menstrual loss.