Menorrhagia - Heavy Mestrual Bleeding
Definition • Causes • Diagnosis • Treatment
Definition
Menorrhagia, which is excessive or abnormally heavy menstrual bleeding, is a frequent complaint needing gynecologic evaluation. A normal menstrual cycle may occur every three to six weeks apart and last up to seven days, resulting in the shedding of up to 80 ml of blood (about five tablespoons). Signs of heavy bleeding include the presence of clots and the need for frequent pad changes (as often as every hour or closer), needing to change pads in the middle of the night, or blood soaking through on to clothing.
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Causes
The causes of menorrhagia can be functional (hormonal), structural (abnormalities of the uterus), and sometimes even unknown. The most common hormonal cause is a lack of ovulation, leading to constant estrogen stimulation of the uterine lining without the regulatory, shedding effect of progesterone. This scenario of anovulatory cycles occurs most frequently in the teenage years and in the decade or so before menopause. Thyroid imbalances or other medical conditions or bleeding disorders are less commonly involved. Structural causes include uterine fibroids/myomas (benign tumors arising in the muscle layer of the uterus), adenomyosis (pockets of uterine lining tissue located in the muscle layer), endometrial (uterine lining) polyps, and IUD’s.
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Diagnosis
A combination of medical history, physical examination, labwork, and radiologic imaging is helpful in determining the cause of menorrhagia. It is helpful to be able to give your gynecologist a recent record of frequency and duration of menstrual periods as well as a complete list of current medications and prior surgeries. A pelvic examination will need to be performed and possibly a Pap smear if due. In some cases an endometrial biopsy (an office sample of the uterine lining) may be needed, as well as thyroid testing. In many cases a pelvic ultrasound will be done to screen for some of the structural causes of menorrhagia.
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Treatment
Medical and surgical options are available for the treatment of heavy bleeding. In general, the hormones in birth control pills seem to be the most effective medical approach. For those women who cannot take “the pill” however, progesterone alone in the form of a shot, a pill, or an IUD can be tried. Oral iron supplements may be needed to stabilize the blood count and help return it to normal.
For those women who fail or cannot use medication, a number of surgical options exist and the appropriate choice may depend on the underlying reason for the bleeding. A “D & C” is most often only a temporary measure and will not solve the problem unless it is done specifically to remove an abnormality inside the uterine cavity such as a polyp.
An endometrial ablation uses any of several different methods to destroy much of the endometrium, the uterine lining where bleeding arises. Although a few women will achieve amenorrhea (absence of periods), most will end up with lighter periods than previously. Some of the highest success rates have been achieved with the NovaSure device, but it is more effective in women with a normal uterus as opposed to those with fibroids (85% in the short term versus 67%).
For women who have fibroids, a myomectomy to surgically remove them is the only option if pregnancy is desired. Indeed, because of the much greater risks involved compared with any other procedure it is usually only appropriate when childbearing needs to be an option.
Uterine artery embolization for fibroids is an inpatient procedure done by a radiologist. Catheters are threaded up through the large blood vessels in the groin to reach the uterus and microspheres of an inert material are injected in an attempt to block off some of the arteries leading to the tumors. The procedure can reduce the amount of bleeding and pain for some women; the myomas may shrink slightly but they do not disappear.
Hysterectomy, or removal of the uterus, is an option for women who have failed in other attempts to control their bleeding. The ovaries do not necessarily need to be removed at the time of surgery, so hysterectomy along does not make a woman menopausal. The uterus can often be removed through a vaginal or laparoscopically-assisted approach on an outpatient/overnight observation bases. Occasionally an abdominal incision will be needed, especially if excessively large fibroids are present or if previous surgery or endometriosis results in extensive scarring in the abdomen.
For more information or to set your preferred appointment, call our Raleigh gynecology office at 919.881.7766 or use our online appointment request form.
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