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Menorrhagia (hypermenorrhoea) Causes, Symptoms and Treatment

The menorrhagia may concern only women between puberty and the menopause. Indeed, they (hyperménorrhées) correspond to abnormally abundant and prolongedmenstruation . This is the most common menstrual disorder reported by women. The amount of blood normally lost during menstruation averages 2 ounces (4 tbsp) and the usual duration varies from 3 to 7 days. A woman with menorrhagia can lose up to 3 oz (6 tbsp) or more and sometimes over a period of more than 7 days. Menorrhagia is sometimes accompanied by abdominal pain affecting the quality of life of women who suffer from it. In some cases, she may be responsible for anemia.

Nearly 1 in 20 women aged 30 to 49 years old consult a doctor each year because of menorrhagia. Of course, it’s still a subjective assessment, since it’s hard to measure the amount of blood lost during menstruation.

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In addition to menorrhagia (which is an exaggeration of menstruation), unusual bleeding (more or less important) can occur between 2 periods of menstruation: if they are very light and occasional, we speak of ”  spotting  “; if they are important or almost permanent, they are called ”  metrorrhagia  “. They do not always have the same meaning as menorrhagia: menorrhagia are rules whose duration and abundance are important (always or recently); while spotting and metrorrhagia are bleeding that is not related to the cycle.

The presence of uterine fibroids (benign tumor of the lining of the uterus) can cause heavy periods(menorrhagia) and bleeding between periods (metrorrhagia) but also one or the other.

Note  : if menorrhagia can be painful, metrorrhagia and spottings, if light, are most often painless. The pain is produced by the contractions of the uterus and not by the bleeding itself and having pain does not mean that the bleeding is serious.

Causes of Menorrhagia (hypermenorrhoea)

The periods are the elimination, at the end of an ovulatory cycle, the inner wall of the uterus (endometrium), consisting of abundant cells and blood. Menstruation is not a simple bleeding but a “moulting” of the inner lining of the uterus. This, to accommodate a pregnancy, must indeed be made up of “fresh” cells. When the ovulation of the month has not been followed by pregnancy, the fall of the hormones in the blood causes evacuation of the internal lining of the uterus and contractions of the uterus which detach the endometrium and expel it. . Once the menstrual period is over, the endometrium is reformed in the next cycle in anticipation of the next ovulation and

The most common source of unusual vaginal bleeding is hormonal fluctuation . The secretion of estrogen and progesterone influences the growth of the endometrium and ovulation; their drop in the blood causes the appearance of the rules. But it happens that ovulation does not occur (anovulatory cycle) or later. The endometrium then continues to form, until the uterus eventually expels it anyway. The endometrium has developed longer and therefore more and there is more thickness to eliminate, which results in menorrhagia .

The anovulatory cycles are common in early adolescence and the period of perimenopause , but they can also occur anytime until menopause. A delay in menstrual periods of a few days may be followed by more heavy menstruation than usual because ovulation has been delayed.

A late menstrual period of more than 15 days accompanied by significant bleeding can sometimes be a miscarriage . In this case, a pregnancy test is positive.

It should be noted that miscarriages occurring less than 3 months of age are almost always related to the non-viability of the embryo. A miscarriage usually does not translate into a fertility problem. Only if it occurs 3 or more times should an exploration be done.

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Other causes of menorrhagia or unusual vaginal bleeding :

  • The presence of benign tumors in the uterus, such as uterine fibroids or polyps (an elongated outgrowth that occurs on a mucous membrane), is also a common cause of menorrhagia or unusual bleeding, particularly after age 35;
  • Taking hormonal treatment (contraception, menopause treatment, and fertility treatment) can lead to menorrhagia and irregular bleeding (spotting or metrorrhagia). Many users of contraceptive pills, especially when they are not adapted, can observe a “spotting” or metrorrhagia.
  • Copper intrauterine device (IUD) users may have much more menstrual bleeding.
  • Hormone IUD users generally have much lower rules … Except for a few women who may have menorrhagia;
  • Spotting (mild bleeding) after sexual intercourse may be due to a poorly adapted pill or hormone treatment , or inflammation (usually mild) of the cervix. But it can also be due to a genital infection or cervical cancer. It must therefore absolutely involve a consultation if it reproduces itself;
  • The endometriosis , abnormal development of endometrial tissue outside the uterus, can be linked to heavy periods, evacuated into the tubes and not the vagina. Severe abdominal pain that occurs after the menses, in the days following the cessation of bleeding, is highly suggestive of endometriosis;
  • Unusual bleeding in a woman over 40 using no contraception may be related to inflammation or cervical cancer and require consultation as soon as possible.
  • Bleeding in a menopausal woman is not menorrhagia. These are haemorrhages and they must prompt consultation.
  • Bleeding in a pregnant woman is never menorrhagia, since a pregnant woman has no period. These bleeds must result in prompt medical consultation.

Here are other possible causes, but rarer:

  • Other disorders of the genitals: pelvic infection (salpingitis), ovarian cancer, endometrial cancer;
  • Taking certain drugs (anticoagulants, aspirin taken in large quantities, chemotherapy);
  • Various diseases: thyroid disorders, lupus, a hereditary hemorrhagic disease such as von Willebrand disease;

Complications

The most common complication of menorrhagia is iron deficiency anemia ( iron deficiency anemia ). Heavy or repeated bleeding depletes iron stores in the body, which cannot produce enough red blood cells. About 10% of women of childbearing age have iron deficiency anemia. It is enough, to have anemia, to have menses abundant or a little long (more than 7 days) and frequent (every 25 days …) and not to absorb enough iron.

The bleeding sudden major or very painful can cause fainting or severe weakness. They then require emergency room consultation.

The pain is not necessarily related to the severity of the bleeding but especially to their abundance and the personal sensitivity of each woman.

The presence of clots or the dark color of bleeding is not signs of seriousness. Coagulation helps to limit blood loss. When exposed to the air, the blood oxidizes and darkens. The menstrual blood is red when it is eliminated immediately. If it is dark and contains clots, it simply means that the endometrium has come off the uterus for some time (a few hours) before the uterine contractions evacuate it. This phenomenon does not, in itself, have a worrying significance.

Symptoms of menorrhagia (hypermenorrhoea)


Here are the signs that can alert menorrhagia and should lead to: 

  • Blood flow requiring one or more sanitary napkins per hour for several hours;
  • The need to use several protections (eg pad and towel) at the same time;
  • The need to change protection during the night. The need to use protections at unusual times in the cycle.

Other symptoms

  • Sometimes a constant pain in the lower abdomen during menstruation (the intensity of pain varies from woman to woman).
  • Sometimes, fatigue and abnormal breathlessness on exertion (signs of anemia).
  • Fever, pain triggered by sexual intercourse are suggestive of pelvic infection (endometritis, salpingitis), especially if they have followed abnormal losses and if the woman is at risk of sexually transmitted infections: under 25 years old , several partners, no condoms.

People at risk for Menorrhagia (hypermenorrhoea)

  • Adolescent girls at the beginning of the fertile period. Menstruation can be abundant for 12 to 18 months after the first period;
  • Women during the premenopausal period;
  • Women with copper IUD, uterine fibroids, uterine polyps, or with any of the conditions listed on the previous page (see causes).

Risk factors

  • The use of a   copper intrauterine device (IUD) can increase the abundance of the menses and lengthen them; the use of a  Mirena  (a progestogen-containing device) almost always significantly decreases the menstrual flow (even to the point of arrest); but in some women it can cause spotting (especially at the beginning of use);
  • Hormonal contraceptives in general (contraceptive pills, progestin injections, “patch”, vaginal ring, use of the “morning after” pill) can over time lead to bleeding or “spottings”. Progestogen treatments thin the endometrium, making it more fragile and more likely to bleed;
  • Taking medication (among others: anticoagulants, aspirin, and chemotherapy).

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Prevention of menorrhagia (hypermenorrhoea)

Screening measures
A woman who is menstruating should consult a doctor for a gynecological examination with smear twice within one year, and then at least every three years. This is the time to talk about too much rules if that’s the case. But of course, it is advisable to consult for this specific problem:

  • if menstruation is very abundant, very painful , very frequent or accompanied by anemia, since puberty in a young girl or for a few weeks in an adult woman;
  • in front of unexplained and unusual symptoms (abdominal or pelvic pain, menstrual problems, pain during sex, signs of infection, etc.);
  • in case of significant or unusual bleeding , recent onset.
Basic preventive measures
The prevention of menorrhagia and unusual bleeding depends on the situation.

  • In women with menorrhagia since adolescence without identified cause (long periods or more or less painful), menorrhagia can be treated with anti-inflammatory drugs (ibuprofen) during the first 5 days of the cycle. Taking a contraceptive pill removes the rules to replace them with deprivation bleeding, which is usually less abundant. The Mirena Hormone Intrauterine Device ( IUD ) can be offered to very young women with very painful or heavy menstrual periods (sign of endometriosis).
  • In women with recent menorrhagia after several months or years of normal menstruation, the cause of bleeding should be sought (see above) before proposing treatment;
  • The copper intrauterine device users may have longer rules or heavier during the months after insertion of the device; treatment is taking nonsteroidal anti-inflammatory drugs (ibuprofen) and iron (to prevent anemia);
  • The hormonal contraceptives (pills, injections, patch, vaginal ring, Mirena) may be accompanied by “spotting” (light and occasional bleeding, but sometimes repeated) who, it is very common, justifies taking ibuprofen or a consultation to change contraception.

Medical treatment of menorrhagia (hypermenorrhoea)

Treatment depends mainly on the cause and severity of bleeding , their impact on social and emotional life, the age of the woman, etc. The menorrhagia can be caused by a disease it is essential to diagnose and treat (uterine fibroids, polyps, infection, cancer, etc.). In adolescent girls and pre-menopausal women, menorrhagia is more common . In this case, measures can be taken if necessary to avoid iron deficiency anemia, the most common complication.

Having heavy periods can lead to worry, fatigue and frustration. But it is not necessarily serious or disturbing. It will be important to take the time to talk to your doctor and ask him all the questions that come to mind.

Before seeing the doctor. Take notes on menstruation (the date of onset, frequency, number of days, abundance of blood loss, and other disturbing symptoms) to better answer the doctor’s questions.

pharmaceuticals

Nonsteroidal anti-inflammatory drugs . Nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin, Nurofen) reduce menstrual flow and reduce abdominal pain. They are very effective against the menorrhagia of girls, those who use copper IUDs, as well as the “spotting” and metrorrhagia that occasionally accompany contraception or hormone therapy (if spotting and metrorrhagia persist, you should consider changing the pill …)

Avoid taking aspirin as it contributes to bleeding.

Antifibrinolytic. These drugs can sometimes reduce bleeding but their effectiveness is inconsistent. They work by facilitating the coagulation of blood in small blood vessels.

Hormonal treatments

Hormone therapy tablets . When the symptoms of menorrhagia are judged to be painful by the woman or are harmful to her health, a hormonal treatment may be prescribed: the low-dose contraceptive pillsynthetic progestins or natural progesterone (Utrogestan, Prometrium) in tablets.

Injections of medroxy-progesterone acetate (Provera). It is a contraception blocking cycles for about 3 months. This method is very little used. It is sometimes effective but may be accompanied by a temporary disappearance of menstruation or, on the contrary, irregular menstruation. In addition, unlike other treatments, it is not possible to stop the effects of a Provera injection once it has been done. The comfort of use of this method is therefore inconstant.

Intrauterine device with progestin . Progestins (progesterone-related substances) can be delivered directly into the uterus through an intrauterine device, the Mirena or Jaydess IUD.(smaller, for women who have not yet had children). It is implanted for a maximum of 5 years for Mirena and 3 years for Jaydess. It thins the wall of the endometrium and thickens the mucus of the cervix (which prevents sperm from entering the uterus), without the side effects associated with conventional oral hormone treatments. Its effectiveness in reducing menorrhagia (in the absence of a cause requiring treatment) is important if it is well tolerated and can be withdrawn at any time. It is normal for bleeding to occur randomly in the first few months. However, it sometimes has disadvantages with a risk of acne and weight gain in women who are overweight (or who have gained a lot of weight while on a pill or during pregnancy).

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Talk to your doctor about all these possibilities and ask them to describe the advantages, disadvantages and side effects.

When the hormonal treatments described above are not effective in reducing menstrual flow , the doctor may suggest danazol (Danatrol, Cyclomen) or a gonadotropin-releasing hormone (a hormone produced by the hypothalamus also called LHRH for luteinizing hormone- hormone releasing ). Danazol produces an artificial menopause by blocking the secretion of the ovaries. It causes most women to stop menstruation . These 2 drugs have side effects sometimes important, so they are used only as a second resort.

Exploration and surgical treatments

In a small number of cases, when the cause of bleeding is not known or cannot be treated with a drug, further investigations or surgical procedures may be offered.

Ultrasound. It is a simple and painless examination. It allows to visualize the shape of the uterus and to diagnose certain causes of bleeding (fibroma, polyp, endometrial hypertrophy , cancers ) or, on the contrary, to indicate that the uterus is perfectly normal and so to reassure on the benignity of the menorrhagia and other bleeding.

Hysteroscopy. This method has diagnostic and therapeutic functions. First, the hysteroscopy allows the surgeon to see on a screen the internal state of the uterus, which allows him to precisely determine the cause of menorrhagia (presence of polyps, cysts, etc.). It is by using a hysteroscope that the surgeon will make his observations. It is an elongated instrument equipped at its end with an optical system. Hysteroscopy is also used for removal of polyps and endometrial ablation.

Endometrial ablation. Endometrial ablation is the most commonly used surgical treatment to reduce heavy bleeding associated with excessive development of the endometrium. This procedure involves thinning the inner lining of the uterus using different techniques. It is only used in patients who have very heavy bleeding and who do not have uterine disease (large fibroids, polyps, cancer). Endometrial ablation results in a temporary cessation of menstruation or reduction. However, the effect of treatment may only last a few years. About 10% of women who have had endometrial ablation will have to undergo a hysterectomy later. Ablation of the endometrium reaches the capacity to become pregnant. It can therefore only be proposed

Curettage . Curettage consists of scraping the superficial layer of the uterine wall. It is rarely used. It leads to a reduction in menstrual flow for the next few cycles, making it an effective approach in the short term only. It is reserved for cases that are refractory to other treatments or as a diagnostic means of last resort. This procedure also removes a uterine polyp.

hysterectomy. This is an operation to surgically remove the uterus. Traditionally, this removal of the uterus was common practice to stop heavy bleeding. Today, it is a treatment of last resort because other options are available to women. Hysterectomy offers a permanent solution, and can of course only be practiced in women who have definitively renounced any pregnancy. One in five women now undergo a hysterectomy in North America and one in 10 women in France before the age of 60 and in more than half of the cases, this intervention is done to treat menorrhagia. Hysterectomy requires general anesthesia. It can be done abdominally or vaginally, or laparoscopically (insertion of a thin flexible tube into the abdomen),

Hysterectomy is not a benign intervention: it can lead to chronic pain, sexual dysfunction, incontinence. It should only be performed if the bleeding is not controlled by another method or if it is true bleeding that endangers life.

Other treatments

Iron supplements. If anemia is detected (by a blood test) or if the ferritin level is too low, the doctor prescribes iron supplements.

Note. In all cases, iron supplements should be supervised by a health professional.

Hygiene tips

  • To rest. Menorrhagia often leads to fatigue. It is important to rest as soon as you feel the need;
  • Have a healthy diet  ;
  • Doing the exercise regularly, moderately. Exercise helps to reduce pain by inducing the secretion of endorphins, natural painkillers.
  • Do not participate in blood donations.

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