Menorrhagia (Heavy Menstrual Bleeding) - Causes & Treatment

Menorrhagia is a gynaecological condition with extremely heavy or prolonged menstrual bleeding. It is characterized by bleeding lasting more than seven days and involves more blood flow than is typical during the menstrual cycle. The bleeding may be so much that the person may need to change the tampon or pad every one to two hours.

When a woman has menorrhagia, the periods would be heavy that they interfere with daily life and normal activities. Other signs and symptoms of menorrhagia may include:

1. Menstrual flow that soaks through one or more pads or tampons every hour for several hours in a row
2. Menstrual flow that lasts over seven days
3. Need to change pads or tampons during the night
4. Need double sanitary protection to control the bleeding
5. Having constant abdominal pain 
6. Presence of blood clots in the menstrual flow
7. Dark red, pink, or rusty colouration of the blood
8. Symptoms of anaemia, such as fatigue, lack of energy, or shortness of breath
9. Reduction in the overall quality of life

Menorrhagia in a woman can be chronic or occasional. This condition has a wide range of potential causes. The causes of menorrhagia include:

1. Hormonal imbalance: There is a balance between progesterone and estrogen hormones during a normal menstrual cycle. These hormones are necessary for building the lining of the endometrium in the uterus. If there is an imbalance in these hormones, it may lead to heavy menstrual bleeding. The hormonal balance can be caused due to thyroid disease, obesity or overweight, anovulation, and polycystic ovary disease.
2. Dysfunction of ovaries: The body does not produce progesterone hormone when the ovaries are not functioning. Progesterone is necessary for maintaining the lining of the endometrium. Therefore, in the absence of progesterone, the bleeding will be increased.
3. Polyp: Small growth on the inner lining (endometrium) of the uterus. It may also cause heavy bleeding during the menstrual cycle.
4. Uterine fibroids: Some women may experience benign uterine tumors during their childbearing age. These may cause heavier bleeding. 
5. Intrauterine device (IUD): Non-hormonal intrauterine devices (IUDs) as a part of birth control measures may result in menorrhagia. 
6. Cancer: Excessive menstrual bleeding may be caused due to cervical or uterine cancer, especially if the woman has a history of abnormal Pap smear tests.
7. Pregnancy complications: Women with placenta previa or low-lying placenta may have heavier than normal bleeding. 
8. Medications: Certain drugs, such as enoxaparin, warfarin, estrogen and progestins, may cause heavy bleeding as a side effect.  
9. Other causes: The other causes of menorrhagia include kidney disease, liver disease, inherited bleeding disorder, and adenomyosis.

Generally, the risk factors vary with age and the presence of other medical conditions that may explain the occurrence of menorrhagia in a woman. The following are the probable risk factors of menorrhagia:

1. Fibroid
2. Uterine polyp
3. Uterus cancer
4. Diabetes
5. Problems related to thyroid
6. Endometriosis
7. Bleeding disorder
8. Pelvic infection

A woman cannot prevent all the causes of heavy bleeding. However, it is advised to consult a doctor and start appropriate management of the menorrhagia to prevent it from worsening. The following steps will help ease the heavy bleeding. The woman should:

1. Drink plenty of water.
2. Include more green leafy vegetables and whole grains in the diet.
3. Avoid any kind of physical or psychological stress.
4. Maintain a healthy weight and exercise regularly.

The primary care doctor will generally be able to diagnose menorrhagia based on the symptoms, medical history of the woman and a physical examination. The doctor will do a complete physical examination including a pelvic exam. The doctor may also ask the woman to track her periods and the number of pads or tampons she uses for a few months. However, the doctor may also recommend the following additional tests to diagnose menorrhagia.

1. Blood test: A blood test is done to check for anaemia, clotting disorders, and thyroid disease. 
2. Ultrasound of the uterus: Ultrasound is done to view the uterus and check the presence of any lesions or tumors.
3. PAP test: Pap smear test is done to find any kind of infection, inflammation or presence of any tumor in the cervix.
4. Hysteroscopy: A procedure done using a tiny camera to check for the presence of fibroids, polyps, or other problems in the lining of the uterus, that might cause heavy bleeding. 
5. Endometrial biopsy: A test done to check the lining of the uterus for cellular abnormalities or tumors.
6. Transvaginal ultrasound: This test recognises the chances of fibroid and ectopic pregnancy.

How to prepare for the doctor's consultation?

1. Prepare for the doctor consultation in advance: Recent studies have shown that the person who books the appointment in advance can interact with the doctor in a better way. If the patients book an appointment beforehand, they have extra time to list down their symptoms.
2. Explain what exactly the feeling is: No one can understand the symptoms better than the patients themselves. So, the patient should tell all the symptoms to the doctor in a detailed manner. The patient should provide small details such as stomach ache and onset of fever. 
3. Do not forget to ask questions: the patient should always ask questions about the type of treatments and the possible side effects associated with the treatments. The patient must request the doctor to explain the diagnosis if any diagnostic tests have been recommended.

The doctor will determine the type of treatment for menorrhagia depending on the cause of the bleeding and the severity of the bleeding. The doctor will also consider the age, general health, medical history and how well the patient responds to certain medications, procedures, or therapies. Some treatments are ongoing, and some are done one time. A patient must discuss all the options with the doctor to decide the best treatment option for the condition. Following are the list of treatment methods for menorrhagia.

Menorrhagia treatment without surgery

1. Oral progesterone: It helps in balancing hormones and reduces menorrhagia.
2. Non-steroidal anti-inflammatory drugs (NSAIDs): Drugs such as ibuprofen and naproxen can help in reducing menorrhagia and help suppress painful cramps. 
3. Oral contraceptive: Oral contraceptives can also be used to decrease abnormal menstrual flow and regulate the normal menstrual cycle.
4. Tranexamic acid: This drug helps increase the clotting of the blood, resulting in the reduction of blood loss.
5. Iron supplements: Patients with menorrhagia have excessive loss of blood. It may result in iron deficiency. The doctor may also prescribe iron supplements to counter low iron levels. 
6. Hormonal intrauterine devices: Progestin, levonorgestrel, is released by intrauterine devices. This drug helps in reducing blood loss by thinning the uterine lining. It also provides relief from cramps. 

Menorrhagia treatment with surgery

1. Dilation and Curettage: In this procedure, the outermost lining of the uterus is removed. In most cases, excessive bleeding is stopped in one surgery, but some patients may need more than one surgery.
2. Endometrial Resection: This process is done in women having very heavy bleeding. An electrical wire loop is used to remove the endometrial lining of the uterus. Pregnancy is generally not recommended after this procedure.
3. Endometrial Ablation: It is a procedure in which all or a section of the endometrial lining of the uterus is destroyed. In most cases, the surgeon recommends sterilization after the surgery.
4. Uterine Artery Embolisation: This is a surgical procedure done to shrink the non-cancerous tumors (fibroids) in the uterus. In this surgery, a device is inserted through the thigh artery and then guided to the uterus. Small gelatin particles are injected through the device to the artery that supplies blood to the fibroids resulting in blockage of the blood supply and eventually making the fibroids shrink. 
5. Hysterectomy: It is a surgical procedure for the removal of the cervix and uterus. In some cases, the surgeon may also remove ovaries. It is a permanent procedure that causes sterility and ends menstrual periods.

If menorrhagia is not treated in time, then the condition can cause serious health issues and can also be life-threatening. The following are some of the risks and complications of menorrhagia:

1. Anaemia: Menorrhagia can lead to blood loss anaemia because of the continuous loss of blood from the body. Due to this, there is a reduction in the count of red blood cells in the body, further leading to iron deficiency anaemia.
2. Decrease of the iron level in blood: Menorrhagia involves excess blood loss, resulting in low levels of red blood cells. Reduction in the red blood cell counts leads to iron deficiency. Because of this, the body tries to use the iron stores to make haemoglobin to compensate for the loss of haemoglobin that may lead to iron deficiency. If the condition persists, the patients may have iron deficiency anaemia.
3. Severe pain: Women may also experience cramps along with menstrual bleeding. These cramp episodes can be very painful.

When to see a doctor?

The patient should immediately consult a doctor in case the patient is experiencing any of the following signs or symptoms of menorrhagia:

1. Need to change the sanitary pads or tampons every one to two hours
2. Menstrual bleeding lasts for more than seven days
3. Evidence of spotting or bleeding in between periods
4. The pain due to cramps is more than the usual period of cramps
5. If the patient requires double sanitary protection

Dietary habits play a vital role in the development of any disease condition. However, dietary habits won't stop menorrhagia but eating a diet rich in iron can help prevent anaemia. A woman with menorrhagia should try eating iron-rich foods like:

1. Meat
2. Seafood
3. Beans
4. Dryfruits
5. Fruits like pomegranates and apples
6. Nuts
7. Seeds
8. Leafy green vegetables - spinach

Some of the food items should also be avoided by women who are diagnosed with menorrhagia. These include:

1. Avoid consumption of spicy, salty, sour and heavy foods.
2. Avoid tea, coffee, and cold drinks
3. Avoid smoking and alcohol intake