Fast Facts for Your Health: Heavy Menstrual Bleeding

Basics of Heavy Menstrual Bleeding

Each woman's menstrual period is unique. For some it lasts just three to four days, for others an entire week. Bleeding can be relatively light or heavy and still be considered "normal." But if you experience periods that routinely last more than a week or are so heavy they require you to change your tampon or pad every hour or even to use double protection, you should make an appointment with your health care professional.

You could have a condition known as menorrhagia—the medical term for excessive menstrual bleeding. Menorrhagia is most common in women over 45, although it can affect girls who are just beginning to menstruate. Girls and women who have it sometimes experience cramping or pelvic pain, significant fatigue and anemia (low blood iron) due to the excessive blood loss. Typically, these women find that menorrhagia significantly affects their quality of life, forcing them to scale back on their usual activities or even stay home when they have their menstrual periods.

Diagnosing Heavy Menstrual Bleeding

There are many conditions that can cause excessive bleeding. Your health care professional will investigate a range of possibilities before making a diagnosis and recommending one or more treatment options.

There can be a specific condition or disease that causes your heavy bleeding. These can include:

• pelvic inflammatory disease (PID), a bacterial infection of the pelvic organs that is usually
• sexually transmitted
  
• uterine fibroids
  
• abnormal pregnancy (miscarriage, tubal pregnancy)
  
• endometriosis, a condition in which endometrial tissue (makes up the uterine lining)
• grows outside the uterus
  
• infection, tumors or polyps in the pelvic cavity
  
• certain birth control devices (such as intrauterine devices, or IUDs)
  
• bleeding or platelet disorders
  
• certain medications, such as blood thinners
  
• liver, kidney or thyroid disease
  
• uterine, ovarian or cervical cancer

Your health care professional likely will ask you a series of questions about your menstrual cycle, the length and heaviness of your periods and when you first noticed a change in them. You may need to have some of the following tests as well:

• Complete blood count to test for anemia
  
• Pap test, which involves collecting a sample of cells from the cervix to detect the presence of cancer, inflammation, or infection
  
• Imaging tests such as ultrasound, which uses sound waves to create images of the inside of the body, or hysterosalpingography, which takes X-rays of the reproductive organs after they are injected with contrast dye
  
• Blood clotting tests, to screen for various clotting disorders
  
• Endometrial biopsy, which involves taking a sample of tissue from the uterine lining for examination
  
• Hysteroscopy, a visual examination of the canal of the cervix and the interior of the uterus using a viewing instrument (hysteroscope) inserted through the vagina
  
• Dilation and curettage (D&C), a procedure that involves widening the cervical canal with a dilator and scraping the uterine cavity with a curette. The tissue would then be examined.

Based on the results of these tests and your medical history, your health care professional should be able to determine whether your bleeding has some specific underlying cause. For example, if fibroids or endometriosis is found, that condition may need to be treated. If no structural problem is discovered, your health care professional will consider hormone-related causes that may be causing your excessive menstrual bleeding.

Causes of Heavy Menstrual Bleeding

Heavy menstrual bleeding is most often caused by hormonal imbalances of estrogen and progesterone, which control menstruation. These hormones are more likely to be "off-balance" in younger girls who have just started menstruating and in middle-aged women who are approaching menopause.

Most cases of hormone-related heavy bleeding are caused by a hormonal imbalance or uterine fibroids. Other causes include uterine polyps, ovarian cysts, failure to ovulate, an IUD, pregnancy complications, certain medications and in rare cases, cancer.

Treating Heavy Menstrual Periods

If you are diagnosed with menorrhagia with no specific underlying cause your choice of treatment likely will depend on how severe your symptoms are, your age and your desire to preserve your fertility. Medication, a medication-releasing IUD and surgery are current treatment options.

Medication
First, your health care professional will likely recommend correcting your hormone imbalance with oral contraceptives (OCs) or progesterone therapy. He or she also may prescribe either over-the-counter or prescription nonsteroidal anti-inflammatory medications (NSAIDs)—naproxen (Aleve), ibuprofen (Motrin), and the prescription NSAIDs diclofenac (Cataflam) or mefenamic acid (Ponstel),

Oral contraceptives and progestins help reduce heavy bleeding. Progestins block the effects of estrogen on your uterus. NSAIDs can also help make your periods lighter because they reduce hormone-like chemicals called prostaglandins that cause blood vessels to open, triggering uterine contractions, and they can reduce pain from cramping.

You may also need to take an iron supplement if you are anemic—a common condition for women who have very heavy periods.

Intrauterine Devices (IUD)

An IUD that contains the progestin hormone levonorgestrel may also be recommended to treat heavy bleeding. It is inserted and remains in the uterus for five years or longer where it slowly releases levonorgesterel to decrease menstrual flow.

Surgery

If other treatment options do not reduce your bleeding, one of several surgical procedures might be recommended.

Surgical treatment options for excessive menstrual bleeding either destroy or remove the uterine lining or remove the uterus entirely. Therefore, each surgical option affects your fertility, so you should consider them only if you do not want to become pregnant in the future.

Surgical options include:

• Endometrial ablation. This minimally invasive procedure uses one of several available methods to destroy the lining of the uterus. Using a hand-held probe, a physician may apply an energy source such as radio waves, electricity or microwaves, or freezing gas, to the uterine lining. Or heat may be used—by either injecting heated fluid directly into the uterus, or into a balloon that expands within the uterus and then is removed. Endometrial ablation significantly reduces or stops heavy menstrual bleeding for a majority of the women who have the procedure and risks are relatively low; they vary depending on the type of procedure used. This procedure negatively affects a woman's ability to become pregnant, however.
  
• Endometrial resection. This procedure uses an electrosurgical wire loop to remove the lining of the uterus. It's an earlier form of endometrial ablation techniques used today. Side effects from this procedure include blood in the uterine cavity and a decreased chance of pregnancy, among others, and therefore, endometrial resection is considered higher risk.
  
• Hysterectomy. This surgery, which involves removing the uterus used to be the treatment of choice for excessive uterine bleeding. It's considered major surgery and several surgical techniques are available, with recovery times of between two and six weeks, depending on the type of surgery used. Although hysterectomy remains a treatment option for heavy bleeding—and will stop bleeding permanently once your uterus is removed—less invasive treatments are usually recommended first.
  
• Dilation and curettage (D&C). This procedure involves widening the cervical canal with a dilator and scraping the uterine cavity with a curette. The tissue would then be examined. This procedure often needs to be repeated to treat heavy bleeding.

Be sure to discuss the risks and benefits of each treatment option recommended to reduce your excessive menstrual bleeding with your health care professional. Your age, health history and your interest in becoming pregnant will be part of your decision for which treatment option might work best for you.

Questions to Ask Your Health Care Professional

The following questions may be helpful in discussing your symptoms and treatment options for heavy menstrual periods with your health care professional:

1. My menstrual periods put my life on hold while I try to manage very heavy bleeding. Is this normal?
   
2. What could be causing my periods to be really heavy or longer than usual?
   
3. What tests do you recommend to determine what the cause might be?
   
4. As we work together to figure out why I bleed so much, is there anything I can do to cope with this problem?
   
5. What treatments are available for excessive menstrual bleeding?
   
6. Will my insurance cover the treatments you recommend?
   
7. What side effects are associated with the treatments you've presented?
   
8. Will my heavy periods get better over time if I don't do anything?
   
9. What type of pain relief medication will work best for me during my periods?

Resources

Your Guide to Uterine Health
National Women's Health Resource Center
1-877-986-9472
www.healthywomen.org
An online overview of uterine health, including fibroids. Also available in print.

The Hormone Foundation
The education affiliate of the Endocrine Society
1-800-HORMONE
www.hormone.org
Provides information and resources on hormone-related conditions and treatment options. such as hormone therapies.

National Women's Health Information Center
1-800-994-9662
www.4woman.org
Sponsored by the U.S. Department of Health and Human Services and the Office on Women's Health, site is the federal government source for women's health information.

American College of Obstetricians and Gynecologists
202-638-5577
www.acog.com
Educational pamphlets on "Abnormal Uterine Bleeding" and "Endometrial Ablation" available online or by calling the phone number.

Medem, Inc.
www.medem.com
A physician-patient communications network that provides information about health issues.

Association of Reproductive Health Professionals (ARHP)
202-466-3825
www.arhp.org
An international, nonprofit association of health care providers, researchers and educators provides information and education on reproductive health topics.

Medline Plus
http://www.nlm.nih.gov
Provided by the U.S. National Library of Medicine and the National Institutes of Health, site provides clear and thorough information on menorrhagia and other menstrual disorders.

Sources Consulted

Your Guide to Uterine Health. 2003. National Women's Health Resource Center, Washington, DC.

"Dysfunctional Uterine Bleeding," in The Merck Manual of Diagnosis and Therapy, eds. Mark H. Beers, M.D. and Scott Berkow, M.D., Whitehouse Station, NJ: Merck and Co., 1999. pages 1941-2.

"Heavy Flow: Menorrhagia," in M. Sara Rosenthal, Ph.D., The Gynecological Sourcebook, 4th edition, McGraw-Hill, 2003, pages 33-36.

"Menorrhagia." MedlinePlus Health information, www.nlm.nih.gov.

"Menorrhagia," MayoClinic.com, www.mayoclinic.com.

"Menorrhagia." New York-Presbyterian, The University Hospitals of Columbia and Cornell, www.nyp.org.

Julia A. Shaw, M.D. "Menorraghia," www.emedicine.com. Last updated June 20, 2005.

For more information about severe menstrual pain, visit: "Questions to Ask about Heavy Menstrual Bleeding" and "Menstrual Disorders."