My oldest daughter is getting to an age where she’s starting to ask lots of questions about the body, including female anatomy and function! These informal chats include basic explanations of the role periods play in many women’s lives. While having a regular period serves a physiological purpose (i.e. a clean-out of the lining of the uterus, in preparation for possibly conceiving during the next menstrual cycle), excessively heavy periods can prove troublesome for many women! What follows is an outline of common causes of heavy menstrual bleeding (HMB), and management options.
What is heavy menstrual bleeding?
Strictly speaking, the dictionary definition of heavy menstrual bleeding (which used to be called ‘menorrhagia’) is when a woman loses more than 80mL of blood per menstrual cycle. A more practical definition is that if you think you lose too much blood every month, you have heavy menstrual bleeding! In particular, if the heaviness of your periods interfere with your physical, social, emotional and / or material quality of life.
Many patients come from families where many women experience heavy periods. While having such a wealth of knowledge within your female family members can provide helpful emotional and practical support, it can also have the adverse effect of ‘normalising’ horrendously heavy periods. A better yard stick is if you chat with your good female friends and / or colleagues. Do they also have low iron because of their periods? Do they also have gushes of blood, soaking through their clothes and bedsheets? Either way, if you experience these issues, it’s worth chatting to your general practitioner (GP) about it!
What are the symptoms and signs of heavy menstrual bleeding?
Heavy periods can impact enormously on the day-to-day life of women, and have significant impact on their quality of life.
Symptoms of heavy menstrual bleeding include:
– Needing to change your sanitary wear (pads, tampons, menstrual cup) more often than you would like to
– Regularly passing clots, especially if moderate (the size of a golf ball) or large (palm-sized)
– Experiencing gushing of blood, which soaks through your clothes or bedsheet (known as ‘flooding’)
– Having low iron (or ‘iron deficiency anaemia’) as a result of your heavy periods. Iron deficiency anaemia can result in: fatigue, tiredness, feeling faint if you stand up too fast, shortness of breath during exercise (or even at rest), a rapid heartbeat, and headaches.
Signs of heavy menstrual bleeding include:
– Looking pale
– Having a rapid heart rate and/or rate of breathing
– Drop in your blood pressure when standing up from a sitting position (which is known as postural or orthostatic hypotension)
Is heavy menstrual bleeding common?
Heavy periods are thought to affect approximately one in five women, making them extremely common. So if you get in a lift at work with four other women, odds are at least one of them experiences heavy periods.
What causes heavy menstrual bleeding?
There are several underlying causes of heavy menstrual bleeding, which will be outlined below. Sometimes, women may have more than one underlying condition causing their heavy periods.
At the start and end of a woman’s so-called ‘reproductive life’, her female hormones may not be in sync with each other every month. As a result, she may not actually ovulate every month, and may not shed the lining of her uterus every month. This classically happens during the first few years after you start getting your period (e.g. 12 – 15 years old), and as you approach and then go through menopause (e.g. 45 – 55 years old). This often leads to periods occurring less frequently (e.g. only every 2 – 3 months), and being heavier when they do occur: effectively, you are shedding 2 months’ worth of uterine lining at a time, if you only have a period every 2 months!
Women with Polycystic Ovarian Syndrome (PCOS) may only experience periods every 2 – 6 months. Hence, when they do have a period, it may be quite heavy.
Some hormonal imbalances can cause heavy menstrual bleeding, even if a woman is having a regular period, and ovulating, every month. For example: this can happen if your thyroid gland is under-active, which is known as hypothyroidism.
Fibroids (or ‘leiomyomata’) are non-cancerous overgrowths of the muscle of the uterus (which is called the ‘myometrium’). Fibroids are extremely common, with most women having at least one fibroid by the time they are 40 years old. Fibroids tend to grow increasingly large with increasing age, and tend to be most problematic for women in their late 30s – 50s. (Fibroids shrink down after menopause.) Approximately one in four women have problematic symptoms because of their fibroid(s).
Fibroids can occur in various locations in relation to the uterine muscle: protruding from the outside of the uterus (like an apple hanging from a tree); within the muscle of the uterus; or impinging on the inside of the uterine cavity. The last two locations (known as ‘intramural’ and ‘submucosal’ fibroids) can distort the uterine cavity, increase the surface area of the lining of the uterus, and cause heavy menstrual bleeding.
Polyps are non-cancerous growths that protrude from a mucous membrane, such as the lining of your nose, large intestine, or uterus. The latter, called ‘endometrial polyps’, can cause troublesome vaginal bleeding, which may be: heavy menstrual bleeding; bleeding between periods (‘intermenstrual bleeding’); or bleeding after sex (‘post-coital bleeding’).
Adenomyosis is a non-cancerous overgrowth of the lining of the uterus (the ‘endometrium’), which occurs when the lining grows too deeply, into the muscle of the uterus (the ‘myometrium’). It affects approximately one in four women, and can cause both heavy and painful periods. Adenomyosis tends to cause problematic heavy periods in a woman’s late 30s – late 40s.
Copper intrauterine devices
A known side-effect of Copper (non-hormonal) intrauterine devices (IUDs) is making women’s periods heavier.
While the causes of heavy menstrual bleeding outlined above are non-cancerous, cancerous changes to the lining of the uterus (the ‘endometrium’), and the muscle of the uterus (the ‘myometrium’) can also cause heavy periods. Hence, investigating heavy periods often involves a pelvic ultrasound and / or a biopsy of the lining of the uterus (as outlined below).
Very occasionally, a woman may have a familial or genetic tendency to excessive bleeding. For example: so-called ‘von Willebrand disease’ is a lifelong disorder which impairs a person’s capacity to clot their blood. Women with bleeding conditions such as von Willebrand disease are often troubled by excessively heavy periods.
Some medical conditions are managed by so-called ‘blood thinner’ medications, which impair the ability of a patient’s blood to form clots: for example, heart attacks, irregular heart rhythms like atrial fibrillation, deep venous thrombosis, or pulmonary emboli may be treated with a blood thinning medication. Such ‘blood thinners’ (e.g. aspirin, apixaban, warfarin) can contribute to excessively heavy menstrual bleeding.
What are possible complications of heavy menstrual bleeding?
The main complications of heavy menstrual bleeding include: social impacts (e.g. having to stay home during your period, the embarrassment of ‘flooding’ through your clothes in public); and the symptoms of iron-deficiency anaemia (as outlined above).
How is heavy menstrual bleeding investigated?
Heavy periods are investigated using various types of investigations, such as:
– Physical examination. Your GP and / or gynaecological may ask to feel your tummy, or even do an intimate examination like a speculum examination
– Cervical screening test. If there is a reason to do so, your doctor may ask to perform a cervical screening test (formerly known as a ‘Pap smear’)
– Blood tests. Your doctor may recommend that you have various blood tests taken, such as a ‘full blood count’, ‘iron studies’ and / or ‘coagulation studies’
– A pelvic ultrasound is the cornerstone investigation for heavy menstrual bleeding. Ultrasound helps to diagnose underlying conditions such as fibroids, polyps, and adenomyosis.
– Your gynaecologist may recommend a biopsy of the lining of the uterus. This endometrial biopsy may be completed while you are awake, or may need a general anaesthetic.
– Your gynaecologist may recommend a so-called ‘hysteroscopy’, which is when a patient is anaesthetised, and a small (5mm) video camera is inserted through the vagina and cervix, to look at the lining of the uterus. Hysteroscopy helps to diagnose endometrial polyps, and fibroids that are distorting the uterine cavity.
How is heavy menstrual bleeding treated?
Working out the cause of your heavy menstrual bleeding guides the appropriate management. Treatment of your heavy periods may involve some combination of the following:
– Iron supplementation (using tablets and / or an iron infusion through a drip into your vein)
– Non-hormonal medications, such as tranexamic acid
– The combined oral contraception pill (or ‘birth control pill)
– A progesterone-containing intrauterine device
– An injection of a progesterone-containing medicine pellet into the padding of your tummy every three months
– Administration of a so-called ‘GnRH agonist’ medication, either by a monthly injection into your tummy, or a nasal spray twice a day
– Seeing an ‘interventional radiologist’ to have a procedure which blocks the blood supply to a fibroid
– Surgery to remove the cause of the problem (e.g. a ‘polypectomy’ to remove a polyp, or a ‘myomectomy’ to remove a fibroid)
– Surgery to burn (‘endometrial ablation’) or remove (‘endometrial resection’) the lining of the uterus
– Surgery to remove the uterus itself (a ‘hysterectomy’)
You can see how the options listed above go from least to most aggressive. Your Maven Centre clinician can talk you through which options are appropriate for you. It may be appropriate to try the least invasive options first: if that option doesn’t have the desired effect, you may then proceed to try more aggressive options.
Other tips to manage heavy menstrual bleeding
In addition to the medical and surgical options outlined above, the following may prove helpful:
– Talk to your family and friends about your heavy periods! They may be able to recommend some approaches that helped them.
– Iron-rich diet. A diet rich in red meat can help to provide additional iron, to replace what you are losing during your period.
– Try different types of sanitary wear, and change it frequently
– See your GP, to discuss whether investigations and / or referral to a gynaecologist are needed
When should you see a doctor about your heavy periods?
As mentioned in the introduction, if you think your periods are too heavy: they are! It’s worth seeing your GP, to have the appropriate investigations completed (e.g. blood tests, a pelvic ultrasound). Referral to a gynaecologist (such as one at Maven Centre) may be needed!