Heavy Periods

Heavy and/or prolonged periods, often referred to as menorrhagia, are a very common gynaecological problem. Although, in the majority of cases of menorrhagia there is nothing seriously wrong with patient, the problem could be distressing enough to badly affect the patient's quality of the life.

When should the periods be considered heavy?

The period is considered heavy if the menstrual flow exceeds the normal amount, which is 80ml or continues for longer than 8 days. However, as measuring the amount of blood loss is not feasible, the following subjective features are usually used as indicators of heavy periods:

1. Patient describes the blood loss as flooding with very frequent change of tampons or pads.
2. Passage of large clots for more than 2 days
3. Affecting general health e.g. becoming anaemic
4. Disrupting social or working life

Are there other symptoms?

Women with menorrhagia often experience cramping pain with the passage of clots.

What causes heavy periods?

The two most common causes of menorrhagia are dysfunctional uterine bleeding and fibroids.

1. Dysfunctional uterine bleeding: this is diagnosed when there is no medical explanation for the heavy periods. The heavy bleeding is thought to be due either to hormonal imbalance or abnormalities in the blood clotting system.
2. Fibroids: these are very common benign growth of the muscle component of the wall of the womb.

Other causes of menorrhagia include:

1. Polyps: these are small growths of the cervix or lining of the womb
2. Endometriosis
3. Patients receiving anticoagulant medications such as warfarin
4. Patients with certain bleeding disorders
5. Rarely, cancer of the lining of the womb could be the cause of heavy periods. This is extremely rare under the age of 40, but should be excluded in all women with menorrhagia over the age of 45.

In younger women heavy periods are most often due to a temporary hormone imbalance, which eventually corrects itself.

What should I do if I think I have heavy periods?

It is not always necessary to consult a doctor for heavy periods if it is not affecting your life. However, if you have some of the above indicators of heavy periods, if you have noticed a recent significant increase in your menstrual flow or if you are above the age of 45 you should see your doctor.

What investigations may I need?

Pelvic examination, transvaginal ultrasound scan and a full blood count are usually necessary. If you are over 40, a biopsy of the lining of the womb will be required to rule out any abnormality in the lining of the womb. An examination called a hysteroscopy may be required depending on the findings of the ultrasound scan and the biopsy. This involves placing a fine camera through the neck of the womb to inspect the lining of the womb.

What are the treatment options for heavy periods?

If the periods are regular, the following options could be considered in the order given here:

1. Non-hormonal treatment including tranexamic acid and or mefenamic acid, which could be taken in the first few days of the period to reduce the amount of flow. These medications are very effective in most patients, especially when there is no underlying disease.
2. Hormonal treatment including the contraceptive pill or progestogens. These are given in a cyclical fashion for 3 weeks every cycle. They are very effective, but usually have side effects.
3. The Mirena is a hormone containing contraceptive coil that allows the release of progestogen locally in the womb, thus avoiding the side effects. This is effective in reducing the amount of the menstrual flow, but it usually causes an initial period of irregular bleeding for about 3-4 months.
4. Thermal balloon ablation of the lining of the womb, which involves passing a balloon full of hot water in the womb to destroy its lining. This procedure is usually carried out under general anesthesia as a day case, although can also be performed as an outpatient procedure in selected cases.
5. Hysterectomy will be the last resort when all the other treatment options fail or in women with large fibroids or endometriosis.

If the periods are irregular, there will be no place for the non-hormonal treatment, but all the other treatment options could be considered.

Women with anaemia should receive iron treatment.

Fibroids

What are fibroids?

Fibroids are an extremely common condition affecting about 1 in 3 women. They are benign growths of the muscle wall of the womb and can be found either within the wall (intramural) or protruding internally into the cavity of the womb (submucosal) or externally into the abdomen (subserosal). They vary considerably in size from few mm to a huge size filling the whole abdomen. They can also be found in different parts of the womb including front, back, side, top or bottom. A woman could have a single or multiple fibroids (more than 10).

What problems can fibroids cause?

In many women, fibroids do not cause any problems and are only detected during a routine examination or ultrasound scan. Common symptoms caused by fibroids include heavy periods, pressure symptoms and swelling of the lower abdomen. Pressure symptoms depend on the organs affected. For instance pressure on the bladder could cause frequency of urination, pressure on the bowel could cause indigestion and constipation and pressure on nerves could give rise to pains. Very large fibroids could press on the lungs causing difficult in breathing. Fibroids close to the fallopian tubes could cause mechanical obstruction of tubes resulting in infertility. However, the majority of women with fibroids are able to conceive naturally.

How can fibroids be diagnosed?

Fibroids are usually easily detected either during an internal examination if they are large enough, or by an ultrasound examination of the womb. The latter is usually required to determine the number, size, exact location and type of the fibroids.

How can fibroids be treated?

Fibroids need treatment only if they are causing distressing symptoms, otherwise they are better left alone. They are completely benign and will shrink after menopause.

Women with small fibroids presenting with heavy periods could be offered the same non-surgical treatment options described under "heavy periods" such as non-hormonal medications, hormonal treatment and mirena coil. Larger fibroids are less likely to respond to medical treatment. In young women desiring fertility, the fibroids could be removed surgically by an operation called "myomectomy". In the majority of cases myomectomy requires open surgery, but in selected cases with a single fibroid, the procedure could be carried out with keyhole surgery. In women who have completed their family, hysterectomy is the ideal way of eradicating the fibroids.

More recently, less invasive procedures have been developed to treat fibroids in selected patients keen to preserve their womb. These include uterine artery embolsation and MR guided focused ultrasound treatment of the fibroid. However, these procedures are not widely available and are not suitable for every patient.