Menorrhagia (Hypermenorrhea, Heavy menstrual bleeding) is a condition when normal menstrual cycles are either abnormal amount (more that 80 ml loss of blood) or duration (longer than 7 days) or both.
In menorrhagia women experience excessive bleeding during the menstrual period (more than 80 ml per cycle) or prolonged period of the bleeding – longer than 7 days. The blood loss leads to anemia and impairment of the everyday activities of the woman.
Causes and risk factors
Many organic or functional disorders may be the cause of the condition.
- Organic causes include:
1) Pelvic pathologies – adenomyosis, pelvic endometriosis, fibroid uterus, tubercular endometritis, retroverted uterus, intrauterine device etc.;
2) Systemic – liver dysfunction, congestive cardiac failure, severe hypertension;
3) Endocrinal – hypo-/hyperthyroidism;
4) Hematological – leukemia, platelet deficiency, von Willebrand’s disease, idiopathic thrombocytopenic purpura;
5) Emotional stress
- Functional causes: disturbed hypothalamo-pituitary-ovarian-endometrial regulation, imbalance of the levels of progesterone and estrogen, dysfunctional ovaries;
Intake of anti-inflammatory or anticoagulant drugs put a woman at risk of developing excessive or prolonged periods.
Menorrhagia implies total menstrual bleeding of more than 80 ml per cycle or soaking a pad or tampon less than every two hours for several hours. During the bleeding blood clots are passing.
A woman may experience pain during menstrual periods if menorrhagia is associated with the pelvic inflammatory disease, endometriosis or adenomyosis. Painless menorrhagia may be caused by leiomyoma, defects of coagulation or endometrial cancer.
Severe bleeding results in anemia that leads to fatigue, headache, skin paleness and shortness of breath.
Sometimes the bleeding interferes with everyday activities of a woman.
To estimate the bleeding the counting of the tampons/pads may be helpful. Average tampon holds about 5 ml and the average pad – 5-15 ml of blood.
- The blood test is performed to check if there is no anemia, thrombocytopenia or diseases of the thyroid. If the coagulopathy is suspected coagulogram is required;
- Hormonal testing – the measurement of the levels of estrogen and progesterone, thyroid hormones;
- Pelvic and rectal examination to exclude the bleeding from the cervix or rectum;
- The Papanicolau smear test is used to diagnose infection, inflammation or cancer;
- Endometrial biopsy is required to examine for cancer, endometriosis or other lesions of the uterus;
- Ultrasound study of the ovaries and uterus;
- Hysteroscopy is a video-assisted study of the uterus;
Treatment of menorrhagia depends on the cause of the condition and may include:
1) Conservative therapy
- Iron supplements for iron-deficiency anemia;
- Tranexamic acid to reduce the blood loss;
- Combined oral contraceptives (so-called “pill”) – Dienogest, or oral/injected progestogen – Provera;
- Gonadotropin-releasing hormone agonists – Leuprolide;
- Androgens – Danazol;
- Estrogens – Premarin are used for management of acute bleeding;
- Anti-inflammatory drugs (NSAIDs) – Naproxen, Diclofenac;
2) Surgical measures are required when the medications are not effective and the excessive bleeding is caused by the organic lesions.
- Dilatation and curettage is used rather for diagnostics than for a treatment as long as this surgery provides relief of the bleeding not longer than for 2 months. This procedure can’t be done in women who have pelvic infection diseases;
- Resectoscopic endometrial ablation techniques such as trancervical resection of the endometrium, roller-ball endometrial ablation and endometrial laser ablation;
- Nonresectoscopic endometrial ablation techniques – thermal balloon therapy, heated free fluid, cryoablation, microwave endometrial ablation alternative, radiofrequency electricity;
- Endometrial resection – removal of the endometrium – uterine lining;
- Uterine artery embolization is an effective measure in case of fibroids;
- Hysterectomy – the surgical removal of the uterus;
- Myomectomy is the removal of the uterine fibroids. This surgery is performed when a woman plans to conceive and have a baby in the future.