Family doctor

Summary:

• Most women with regular heavy periods (menstrual bleeding) will have no serious disease present (known as dysfunctional bleeding).
• A small number will have other conditions present such as fibroids, polyps, ovarian cysts, endometriosis, pelvic infections, pre-cancer and cancer of the uterine lining.
• Most of these other conditions can be diagnosed by careful history, examination and appropriate investigations.
• There are many options available for dysfunctional heavy menstrual bleeding. These include medication, a progesterone-releasing intrauterine device (IUD), destruction of the lining of the uterus and hysterectomy.

What is menorrhagia?

Menorrhagia is also known as Heavy Menstrual Bleeding, abbreviated to HMB. More than 80mls of blood loss in one menstrual period is considered to be excessive. It is a common condition and disruptive to well being and quality of life.

It is interesting to note that up to 10% of women will have this amount of blood loss, yet up to a third of women consider that they have heavy periods.

It is thus important to try clarify the extent of heavy bleeding, in discussion with your doctor.

What are the causes?

Ninety percent of women with HMB have regular periods and the majority of these will have no serious disease present. These women are said to be suffering from "dysfunctional" HMB. It is thought that this is caused by hormonal imbalances, but the reasons and process are not yet fully understood.

A small number will have other conditions present. These include fibroids, polyps, ovarian cysts, endometriosis, pelvic or uterine infections (benign conditions). More rarely pre-cancer or cancer of the cervix or uterus may be present. Other rare causes are lack of thyroid hormone (hypothyroidism) and a generalised bleeding tendency.

Diagnosis:

Women with HMB should see a general practitioner who will assess them with a careful history, a general and pelvic examination and possibly blood tests.

Any warning symptoms should prompt referral to a gynaecologist. There is a higher likelihood of the cause not being dysfunctional with these symptoms:

• Sudden increase in the blood loss
• Irregular periods
• Bleeding between periods
• Bleeding after intercourse
• Constant pelvic pain
• Pain with intercourse
• Pain before the period has started

A general physical history and examination may point to anaemia, thyroid problems or a bleeding tendency.

If the uterus is enlarged or anything else abnormal is noted on the pelvic examination the patient should be referred to a gynaecologist.

A blood test may be taken to ascertain if anaemia is present and if so, iron supplementation is recommended. Very rarely severe anaemia will require hospitalisation and blood transfusion. A lack of thyroid hormone can be checked with a simple blood test.

Ultrasound and biopsy

A small number of women with regular HMB will have pre-cancerous changes in the lining (endometrium) of the uterus. This is called Endometrial Hyperplasia, and is associated with a thickening of the lining of the uterus (if there is more lining to be shed with the period, it will be heavier). An even smaller number will have cancer of the uterus. These two conditions are more common with increasing age (over 40-50 years) and with increasing bodyweight.

It is thus recommended that all women with regular HMB over 45 years of age and more than 90kg in weight have an ultrasound of the uterus, to check the thickness of the uterine lining. If it is over 12mm thick, endometrial hyperplasia or cancer is more likely to be present. A pipelle biopsy is then recommended. This is done by a gynaecologist, where a tiny sample of the uterine lining is taken by inserting a very thin sampling probe into the uterus through the cervix. This will show whether pre-cancerous or cancerous changes are present.

Diagnosis of dysfunctional HMB:

Dysfunctional HMB is diagnosed when the following conditions are met:

• There is regular HMB with no "warning" symptoms
• The general and pelvic examination is normal
• The patient is less than 45 years of age and less than 90 kg in weight
• Or the patient is either over 45 years of age or over 90 kg in weight with a normal uterine ultrasound or biopsy.

Treatment of dysfunctional HMB

This may be medical treatment with medication taken by mouth or released into the uterine lining by a special intrauterine device (IUD).

Treatment may also be surgical with destruction of the lining of the uterus (by various means) or hysterectomy (removal of the uterus).

Medical treatment

Medical treatment is usually tried first before resorting to surgical methods. There are various options:

Anti-inflammatory medication (NSAIDs) decreases blood loss by about 30%. These suppress chemicals in the uterus called prostaglandins, which increase bleeding. Examples are ibuprofen (Brufen), naproxen (Naprosyn), mefanamic acid (Ponstan) and diclofenac (Voltaren). These should be taken when the period begins, and will help ease period pains (dysmenorrhoea) as well. Side effects include gastric upsets with nausea, gastric pain and diarrhoea. These medications may worsen asthma.

Tranexamic Acid (Cyclokapron) decreases blood loss by about 40%, by causing the bleeding lining of the uterus to clot more efficiently. Side effects include nausea and leg cramps. This is available in New Zealand only with a specialist recommendation. It does not decrease period pains.

The Combined Oral Contraceptive (The "Pill") decreases blood flow by about 40% and also provides contraception and some relief from period pains. It works by shrinking the lining of the uterus.

The Levnorgestrel intrauterine system (LNG-IUS) is a T-shaped intra-uterine device (IUD), which is inserted into the uterus exactly like a normal intra-uterine device. It releases tiny amounts of a hormone, progesterone, into the lining of the uterus. This causes the lining of the uterus to become thinner, thus bleeding less with each period. Initially there may be some spotting, but effectiveness increases with time. It decreases blood loss by over 90% at the end of the first year of use. It lasts for 5 years, and should be replaced after this. It also provides effective contraception.

Surgical treatment

Endometrial destruction (destruction of the lining of the uterus) can be done by various methods. The aim is to leave very little lining to be shed with each period. This can be done under local or general anaesthetic by laser, heat or freezing. Recovery time is much faster than with hysterectomy.

Hysterectomy involves removal of the entire uterus and thus periods stop permanently. Side effects and time off work are higher than all other methods, and this is recommended only if other less invasive measures fail.

Seeking help:

Talk to your doctor or gynaecologist if you are concerned about heavy periods.