Menorrhagia

For many, a monthly period is an inconvenience, but for a significant number of individuals, it can be a debilitating experience marked by exceptionally heavy bleeding. This condition, medically known as menorrhagia, is far more than just a nuisance; it can profoundly impact daily life, leading to physical discomfort, emotional distress, and even serious health complications like anaemia. Often dismissed as "normal for you" or simply a "heavy flow," menorrhagia warrants attention and understanding. 

This comprehensive guide will shed light on what menorrhagia is, its various causes, how it's diagnosed, and the range of effective treatments available. Our aim is to provide clear, accessible information to empower those affected to seek help and manage their condition effectively.

Menorrhagia is the medical term for abnormally heavy or prolonged menstrual bleeding. While what constitutes "heavy" can vary from person to person, menorrhagia is generally defined as menstrual bleeding that is excessive enough to interfere with a person's physical, emotional, social, and material quality of life. It’s not just a slightly heavier flow; it's a significant amount of blood loss that often lasts longer than a typical period.

Specifically, it often involves:

• Excessive blood loss: Soaking through one or more sanitary pads or tampons every hour for several consecutive hours.
• Prolonged bleeding: Menstrual bleeding lasting longer than seven days.
• Large blood clots: Passing blood clots the size of a 10p coin or larger.
• Impact on daily life: Requiring frequent changes of sanitary products, bleeding through clothes, or needing to restrict activities due to heavy bleeding.

It's important to distinguish menorrhagia from other menstrual irregularities, such as metrorrhagia (bleeding between periods) or polymenorrhoea (frequent periods). Menorrhagia specifically refers to the volume and duration of bleeding during the expected menstrual period.

Menorrhagia is a common gynaecological concern, affecting a substantial number of women of reproductive age. Globally, it is estimated that menorrhagia affects between 10% and 35% of women in their reproductive years. It is a leading cause of iron deficiency anaemia in women and can significantly impact their quality of life, leading to missed work or school days, and affecting social activities.

While menorrhagia itself refers to the symptom of heavy bleeding, it isn't categorised into distinct "types" in the same way some other conditions are. Instead, it's typically classified based on its underlying cause:

• Menorrhagia with an identifiable cause: This is when the heavy bleeding is a symptom of an underlying medical condition affecting the reproductive system or general health. Most cases of menorrhagia fall into this category.
• Idiopathic Menorrhagia (Dysfunctional Uterine Bleeding): In some instances, heavy menstrual bleeding occurs without any identifiable underlying cause. This is often linked to an imbalance in the hormones that regulate the menstrual cycle, specifically prostaglandins and abnormalities in the blood vessels of the uterine lining. This type is also sometimes referred to as Dysfunctional Uterine Bleeding (DUB) when other causes have been ruled out.

The causes of menorrhagia are diverse, ranging from hormonal imbalances to structural abnormalities in the uterus. Understanding the underlying reason is crucial for effective treatment.

Hormonal Imbalance: The most common cause, especially in adolescents and women approaching menopause. An imbalance between oestrogen and progesterone can lead to the uterine lining (endometrium) developing excessively, which then sheds with heavy bleeding. This can occur in conditions like anovulation (when an egg is not released during the menstrual cycle).

Uterine Fibroids: These are non-cancerous (benign) growths of muscle and fibrous tissue that develop in the wall of the uterus. They are very common and can vary in size from tiny to very large. Fibroids can cause heavy bleeding by increasing the surface area of the uterine lining, interfering with the uterus's ability to contract effectively, or affecting blood flow to the endometrium.

Uterine Polyps: Small, benign growths that attach to the inner wall of the uterus and protrude into the uterine cavity. They are often soft and fleshy and can cause heavy or irregular bleeding.

Adenomyosis: A condition where the tissue that normally lines the uterus (endometrial tissue) grows into the muscular wall of the uterus (myometrium). This can cause the uterus to become enlarged and lead to painful and heavy periods.

Intrauterine Devices (IUDs): The non-hormonal (copper) IUD is a known cause of increased menstrual bleeding, particularly in the first few months after insertion.

Complications of Pregnancy: Although less common, a single episode of heavy bleeding can be due to a miscarriage or ectopic pregnancy.

Bleeding Disorders: Rare but significant conditions that affect blood clotting, such as Von Willebrand disease or platelet function disorders, can manifest as heavy menstrual bleeding.

Medications: Certain medications, including anticoagulants (blood thinners) like warfarin or aspirin, and some anti-inflammatory drugs, can increase menstrual bleeding.

Endometrial Hyperplasia: A condition where the lining of the uterus becomes too thick due to an excess of oestrogen and a lack of progesterone. If left untreated, some types of endometrial hyperplasia can develop into uterine cancer.

Uterine (Endometrial) Cancer: While less common, especially in younger women, uterine cancer can cause heavy and irregular bleeding. This risk increases with age.

Pelvic Inflammatory Disease (PID): An infection of the reproductive organs that can cause inflammation and lead to abnormal bleeding, though often associated with irregular bleeding rather than strictly heavy periods.

The primary symptom of menorrhagia is abnormally heavy or prolonged menstrual bleeding. However, this often comes with a range of other distressing symptoms:

• Soaking through one or more sanitary pads or tampons every hour for several consecutive hours.
• Needing to double up on sanitary protection to control menstrual flow.
• Needing to change sanitary protection during the night.
• Bleeding for longer than seven days.
• Passing large blood clots (size of a 10p coin or larger).
• Experiencing constant, severe pain in the lower abdomen during your period.
• Symptoms of anaemia, such as fatigue, weakness, shortness of breath, pale skin, and dizziness.
• Restricting daily activities due to fear of accidents or the need for frequent sanitary product changes.

Diagnosing menorrhagia begins with a thorough discussion of your medical history and menstrual cycle, followed by a physical examination. Your doctor will want to understand the pattern of your bleeding, how much it impacts your life, and any other symptoms you're experiencing.

Diagnostic steps may include:

Detailed Medical History and Menstrual Diary: You might be asked to keep a record of your bleeding patterns, including the number of pads/tampons used, the presence of clots, and the duration of your period.

Physical Examination: This includes a pelvic examination to check for any obvious abnormalities of the uterus or cervix.

Blood Tests:

• Full Blood Count (FBC): To check for anaemia (low red blood cell count), which is a common complication of heavy bleeding.
• Thyroid Function Tests: To rule out thyroid disorders, which can affect menstrual cycles.
• Blood Clotting Tests: If a bleeding disorder is suspected.
• Hormone Tests: To check for hormonal imbalances, though these are often less helpful for direct diagnosis of menorrhagia.

Pap Test (Cervical Smear): To screen for cervical changes or cancer.

Ultrasound Scan: This non-invasive imaging technique uses sound waves to create images of the uterus, ovaries, and fallopian tubes. It can detect structural abnormalities like fibroids, polyps, or adenomyosis.

Hysteroscopy: A procedure where a thin, lighted tube with a camera (hysteroscope) is inserted through the cervix into the uterus. This allows the doctor to visualise the inside of the uterus directly and identify polyps, fibroids, or other abnormalities. Biopsies can be taken during this procedure.

Endometrial Biopsy: A small tissue sample is taken from the lining of the uterus and examined under a microscope. This can help identify endometrial hyperplasia or cancer.

Saline Infusion Sonography (SIS) / Sonohysterography: A procedure where saline solution is injected into the uterus during an ultrasound, which helps to provide clearer images of the uterine lining and detect polyps or small fibroids.

The treatment for menorrhagia depends on the underlying cause, the severity of symptoms, and your desire for future fertility. The goal is to reduce bleeding and improve quality of life.

Medical Treatments

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Medications like ibuprofen or mefenamic acid can help reduce blood loss and relieve painful cramps. They work by lowering prostaglandin levels, which contribute to heavy bleeding.
• Tranexamic Acid: This medication (Brands available: Trenaxa, Pause) helps blood to clot, reducing bleeding. It is taken only during the heaviest days of the period.
• Hormonal Therapies:
  • Combined Oral Contraceptives (COCs): Birth control pills can regulate menstrual cycles, thin the uterine lining, and significantly reduce bleeding.
  • Progestin Therapy: Progestins (synthetic progesterone) can be taken orally, injected (depot medroxyprogesterone acetate), or delivered via an Intrauterine System (IUS).
  • Levonorgestrel-releasing Intrauterine System (IUS) / Hormonal Coil: This is often a highly effective treatment. It releases a small amount of progestin directly into the uterus, thinning the uterine lining and significantly reducing bleeding, often leading to very light or no periods.
  • Gonadotropin-Releasing Hormone (GnRH) Agonists: These medications temporarily stop menstruation and are used for severe cases, often before surgery, by inducing a temporary menopause-like state.
• Iron Supplements: If you are anaemic, iron supplements will be prescribed to replenish your iron stores.

Surgical Treatments

• Dilation and Curettage (D&C): A procedure where the cervix is dilated, and tissue from the uterine lining is gently scraped or suctioned out. It can be used for diagnosis or as a short-term treatment to reduce heavy bleeding.
• Hysteroscopic Myomectomy or Polypectomy: Surgical removal of fibroids or polyps that are causing heavy bleeding, performed through a hysteroscope inserted via the cervix.
• Endometrial Ablation: A procedure that destroys the lining of the uterus. This can significantly reduce or stop menstrual bleeding. It is usually considered for women who have completed childbearing and are experiencing severe menorrhagia. Various methods exist, including heat, cold, or radiofrequency ablation.
• Uterine Artery Embolisation (UAE): A minimally invasive procedure primarily for fibroids, where small particles are injected into the arteries supplying the uterus to block blood flow to the fibroids, causing them to shrink.
• Hysterectomy: The surgical removal of the uterus. This is a definitive treatment for menorrhagia and is usually considered only as a last resort when other treatments have failed, or if there is a severe underlying condition, and the woman has completed childbearing.

While not a substitute for medical consultation, some individuals explore alternative therapies to complement conventional treatments for menorrhagia or to alleviate associated symptoms:

• Herbal Remedies: Certain herbs like Shepherd's Purse, Raspberry Leaf, or Vitex Agnus-Castus (Chasteberry) are sometimes used, often with the aim of balancing hormones or reducing bleeding. Scientific evidence supporting their effectiveness for menorrhagia is often limited, and they should be used with caution and under professional guidance, as they can interact with medications.
• Dietary Changes: A diet rich in iron-rich foods (lean red meat, leafy greens, fortified cereals) can help combat anaemia. Some advocate for reducing caffeine, alcohol, and processed foods, and increasing intake of foods rich in Vitamin K and C, though direct evidence for menorrhagia specific improvement is limited.
• Stress Reduction Techniques: Practises like yoga, meditation, and mindfulness can help manage the emotional distress and anxiety that often accompany chronic heavy bleeding.

• Adolescence: Irregular ovulation can lead to temporary hormonal imbalances.
• Perimenopause: Hormonal fluctuations as women approach menopause.
• Uterine fibroids or polyps.
• Adenomyosis.
• Bleeding disorders.
• Certain medications (e.g., anticoagulants).
• Underlying medical conditions (e.g., thyroid disorders, kidney or liver disease).

• Iron Deficiency Anaemia: The most common complication, leading to fatigue, weakness, and shortness of breath.
• Severe Pain (Dysmenorrhoea): Heavy bleeding is often accompanied by intense menstrual cramps.
• Significant Impact on Quality of Life: Disrupting work, school, social activities, and emotional well-being.
• Increased Risk of Infection: Though less common, prolonged bleeding can increase vulnerability.
• Fertility Issues: If menorrhagia is caused by conditions like fibroids or polyps affecting the uterine cavity.

• Be Prepared: Always carry extra sanitary products, a change of underwear, and dark clothing, especially when out.
• Stay Hydrated and Iron-Rich: Drink plenty of fluids and focus on iron-rich foods (or supplements if prescribed) to combat anaemia and fatigue.
• Track Your Bleeding: Keep a menstrual diary to help you understand your patterns, identify triggers, and communicate effectively with your doctor.
• Prioritise Rest: Heavy bleeding can be exhausting. Listen to your body and allow yourself extra rest when needed.
• Explore Absorbent Products: Consider using highly absorbent sanitary pads or menstrual cups designed for heavy flow, or period-proof underwear, for added security and comfort.

"It's normal to bleed heavily; it's just 'your normal'." 

While individual flows vary, bleeding that severely impacts daily life or causes anaemia is not normal and should be investigated by a doctor.

"There's nothing you can do about heavy periods." 

This is untrue. There are numerous effective medical and surgical treatments available for menorrhagia, offering significant relief.

"Heavy bleeding means you have cancer." 

While cancer is a possible cause, it's a rare one, especially in younger women. Most cases of menorrhagia are due to benign (non-cancerous) conditions like hormonal imbalances or fibroids.

You should see a doctor if:

• You are regularly soaking through one or more sanitary pads or tampons every hour for several consecutive hours.
• You need to change sanitary protection during the night.
• Your period lasts longer than seven days.
• You pass large blood clots (the size of a 10p coin or larger).
• Heavy bleeding impacts your daily activities or quality of life.
• You experience symptoms of anaemia, such as persistent fatigue, weakness, or shortness of breath.
• You experience bleeding between periods or after menopause.

• What is likely causing my heavy periods?
• What tests do you recommend to diagnose the cause?
• What are my treatment options, both medical and surgical?
• What are the potential side effects of the recommended treatments?
• How long will it take to see an improvement in my symptoms?
• Will this treatment affect my future fertility?
• What lifestyle changes can I make to help manage my condition?

• Validate Their Experience: Acknowledge that their pain and heavy bleeding are real and impactful. Avoid dismissive comments.
• Offer Practical Assistance: Offer to run errands, help with chores, or provide a comfortable space to rest when they are struggling.
• Encourage Medical Help: Gently encourage them to speak to a doctor if they haven't already, and offer to accompany them to appointments if they wish.
• Be Understanding: Recognise that menorrhagia can cause fatigue, discomfort, and anxiety, and adjust expectations accordingly, especially during their period.

Menorrhagia, or heavy menstrual bleeding, is a common yet often overlooked condition that can significantly disrupt a person's life. It's crucial to understand that excessive bleeding is not simply a 'heavy flow' to be tolerated; it is a treatable medical condition. By recognising the symptoms, seeking timely diagnosis, and exploring the wide range of available treatments – from simple medications and hormonal therapies to more advanced surgical options – individuals can find effective relief. Empowering oneself with knowledge and seeking professional medical advice are the first steps towards managing menorrhagia and reclaiming control over one's health and daily life.