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Family Health Magazine
WOMEN'S HEALTH

Heavy Menstrual Periods
What are the causes?

In ancient times, the Greeks named the uterus or womb the hustera. They attributed all women's problems to their uterus. The name forms part of the term hysterectomy, referring to the operation to remove the uterus. Fortunately, today we know a lot more about the female reproductive system. As a result, women who suffer from problems with the uterus, such as heavy periods, have more information and treatments available.

Menstruation is a part of every woman's normal reproductive life cycle. However, it can lead to large blood loss for some women. The condition, called menorrhagia (men-or-rage-ya), reduces the quality of life for many women.

What is a normal menstrual period?

The uterus creates a lining each month ready to receive a fertilized egg. If there is no egg to receive, the lining is shed for that month and menstruation occurs. In most women this occurs on a monthly basis. The process occurs over an average period of 26 to 30 days, hence the term menstrual period. It usually lasts four to six days.

Some women have very regular menstrual cycles, others vary by a few days, others by weeks or months. The average blood loss per cycle is 25 to 60 ml or about a quarter of a cup. The first one to two days are usually the heaviest and sometimes accompanied by cramps.

What can cause heavy periods?

The occasional heavy period is usually nothing to worry about. At adolescence and nearing menopause, the ovaries are either starting out or winding up their functional life. Heavy menstruation often happens at these times.

However, if there is a marked change in your menstrual pattern or you have heavy periods most of the time there may be a cause that should be investigated. Persistent heavy periods can result in anemia (low blood count) and can leave you feeling tired or short of breath.

The first day of your period is counted as day one. Ovulation (production of an egg ready to be fertilized) normally occurs around day 14. Sometimes ovulation does not occur every month. This can indicate fluctuating hormone levels and may cause heavy bleeding.

Less commonly, changes in adrenal and thyroid hormones can upset your usual menstrual cycle.

Pregnancy or miscarriage may explain heavy bleeding. This is particularly the case in a sexually active woman who is not using birth control or is using an unreliable method. Bleeding in pregnancy can be mistaken for a menstrual period when it is a tubal (ectopic) pregnancy.

Fibroids are growths of fibrous tissue or smooth muscle in the uterus. Fibroids are a common cause of heavy flow, especially if they lie close to the lining of the uterus. Here they can interfere with the ability of capillaries to close off and stop blood flow. Fibroids occur more often in women in their 30s or 40s.

Polyps are benign growths that grow out of the lining of the uterus. They can be richly supplied with blood vessels and sometimes bleed heavily. Certain types of cancer can result in heavy or abnormal periods. This is an important but less common cause of heavy bleeding.

Heavy periods can be a reflection of a problem with the body's blood clotting system or might signal infection in the uterus. If you have heavy periods, the first step is to talk with your doctor.

What questions might my doctor want to ask me?

Your doctor will want to establish your usual pattern of menstruation. You will be asked about changes in the frequency, duration and quantity of your menstrual period as well as unusual events such as bleeding between periods or pain with intercourse. You may be asked about surgery, pap smears, contraception, hormone therapy, family history, pregnancies or infertility. Your doctor may also ask if you have been under unusual stress or have lost weight.

Is a pelvic examination necessary?

Pelvic examination is usually done by your doctor to check for an enlarged or abnormal uterus, ovaries and tubes. A Pap smear will also usually be done. This is a test for abnormal cells of the cervix that could be associated with cancer.

Endometrial biopsy is another procedure that may be done. During this test, a sample of the lining (or endometrium) of the uterus is taken. This can give information about hormone levels in your body as well as search for abnormal cells. Gynecologists generally perform endometrial biopsy but some family doctors do this procedure.

What other tests might be considered?

Pregnancy should be ruled out with a test. Depending on how heavy the flow is, a blood count should be done and tests of blood clotting or liver function may be considered. Testing of female reproductive hormones is sometimes useful, as are tests of other hormones, such as thyroid. Your doctor may order an ultrasound if the examination shows an abnormal or enlarged ovary or uterus.

What treatments are available?

There are treatments that may help to deal with this problem. Generally, medical treatment is the first approach and then your doctor may suggest surgery.

Many women with heavy periods, whether sexually active or not, benefit from estrogen and progesterone therapy in the form of contraceptive pills. These pills regulate the body's own hormones that may be causing the irregular bleeding. They have other benefits such as reducing cancer of the uterus and of the ovary. Most healthy women who are non-smokers can take contraceptive pills until menopause. Women who should not take the birth control pill include smokers over the age of 35, women with liver disease, hypertension, heart disease or a history of stroke, blood clots in the lung (pulmonary embolism) or legs (deep vein thrombosis).

Some women are helped by taking progesterone alone. This is one approach for smokers who may not be candidates for estrogen therapy.

In certain cases, non-hormone treatments such as anti-inflammatory drugs can reduce the blood flow. These medications also help treat menstrual cramps. Other non-hormone treatments include medications that help blood to clot more normally.

Women with anemia from heavy blood loss may be advised to take iron tablets. These can help replenish iron stores, but they often cause stomach upset and constipation. Adding fibre to the diet or a stool softener can usually alleviate constipation.

Why might I see a gynecologist?

Your family doctor may refer you to a gynecologist if the problem persists or if a more serious cause of abnormal bleeding is suspected.

A gynecologist can perform a biopsy of the endometrium to check for abnormal tissue. Another test may be a hysteroscopy where the inside of the vagina and uterus are inspected using a special fibre optic camera. This can help to diagnose polyps or fibroids and to treat them in many cases.

Some women choose to have surgery to help their problem. For example, endometrial ablation is a procedure that removes the lining of the uterus. This may reduce or eliminate menstrual flow.

When one fibroid causes heavy bleeding or interferes with a women's ability to become pregnant, it can sometimes be removed while leaving the uterus intact. The procedure is known as myomectomy.

Some women choose to have a hysterectomy, where the uterus is removed through the vagina or the abdomen. Women who choose this option are usually in their 40s and do not plan to have more children.

Some women do not wish to have treatment for their heavy periods or do not find a treatment that meets their needs. If you are troubled by heavy periods, discuss your concerns with your family doctor and review your options.