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Monday, August 18, 2025

Periods (heavy)


Heavy Periods (Menorrhagia)

Introduction

Menstrual bleeding is considered normal when it occurs every 21–35 days, lasts 3–7 days, and involves an average blood loss of 30–40 mL. Heavy periods, medically termed menorrhagia, are characterized by excessive or prolonged menstrual bleeding that interferes with a woman’s physical, emotional, and social well-being.

Clinically, heavy menstrual bleeding (HMB) is defined as:

  • Blood loss >80 mL per cycle, or

  • Bleeding lasting longer than 7 days, or

  • The presence of symptoms such as soaking through pads/tampons every 1–2 hours, needing double protection, waking at night to change protection, or passing large blood clots.

It is one of the most common gynecological complaints, affecting up to 30% of women of reproductive age.

Causes of Heavy Periods

1. Structural (Uterine Pathology)

  • Fibroids (leiomyomas): benign smooth muscle tumors, especially submucosal fibroids.

  • Endometrial polyps: benign growths that distort the endometrial cavity.

  • Adenomyosis: endometrial tissue embedded within the myometrium.

  • Endometrial carcinoma or hyperplasia: especially in perimenopausal women.

2. Hormonal and Systemic Causes

  • Anovulatory cycles: common in adolescents and perimenopausal women, leading to unopposed estrogen exposure and irregular shedding.

  • Polycystic Ovary Syndrome (PCOS): hormonal imbalance and chronic anovulation.

  • Thyroid disease: both hypo- and hyperthyroidism.

  • Coagulation disorders: von Willebrand disease, platelet function defects, clotting factor deficiencies.

  • Liver or renal disease: reduced metabolism of clotting factors and hormones.

3. Iatrogenic / Medications

  • Anticoagulants: warfarin, heparin, direct oral anticoagulants.

  • Intrauterine devices (copper IUDs): may increase bleeding.

  • Hormonal therapies: progestogen-only methods, or inconsistent contraceptive use.

4. Pregnancy-related

  • Early miscarriage or incomplete abortion.

  • Ectopic pregnancy.

Pathophysiology

The endometrial cycle is regulated by estrogen and progesterone. Heavy bleeding can occur due to:

  1. Increased endometrial surface area (fibroids, adenomyosis).

  2. Defective clotting or fibrinolysis (systemic disorders).

  3. Unopposed estrogen leading to endometrial hyperplasia.

  4. Vascular abnormalities within the uterus.

  5. Anovulatory cycles causing prolonged proliferative phase without progesterone withdrawal.

Clinical Features

  • Menstrual bleeding lasting >7 days.

  • Requiring frequent pad/tampon changes (every 1–2 hours).

  • Passage of large clots.

  • Interference with daily activities.

  • Associated symptoms:

    • Anemia (fatigue, pallor, shortness of breath).

    • Pelvic pain or pressure (fibroids, adenomyosis).

    • Symptoms of systemic illness (thyroid dysfunction, clotting disorders).

Diagnostic Evaluation

1. History

  • Menstrual history: onset, duration, cycle pattern, severity.

  • Obstetric history.

  • Medications (anticoagulants, contraceptives).

  • Family history of bleeding disorders.

  • Symptoms of anemia.

2. Physical Examination

  • Vital signs (hemodynamic stability).

  • Signs of anemia.

  • Pelvic exam: uterine enlargement (fibroids), tenderness (adenomyosis).

3. Investigations

  • Pregnancy test (hCG).

  • CBC (complete blood count): hemoglobin, hematocrit.

  • Iron studies (serum ferritin).

  • Coagulation profile: PT, aPTT, von Willebrand factor.

  • Thyroid function tests (TSH, free T4).

  • Pelvic ultrasound: fibroids, polyps, adenomyosis.

  • Saline infusion sonohysterography (SIS) or hysteroscopy for intrauterine pathology.

  • Endometrial biopsy: women ≥45 years or those with risk factors for endometrial hyperplasia/cancer.

Management of Heavy Periods

Treatment depends on underlying cause, severity of bleeding, fertility desires, and age.

1. General and Supportive Measures

  • Iron supplementation: ferrous sulfate 325 mg orally once or twice daily for iron-deficiency anemia.

  • Dietary advice: iron-rich foods (red meat, leafy greens, beans).

  • Hemodynamic stabilization: IV fluids, blood transfusion if severe anemia.

2. Medical Management

a) Non-Hormonal Therapies

  • Tranexamic acid: antifibrinolytic, reduces blood loss by 40–60%.

    • Dose: 1 g orally 3–4 times daily during menstruation (max 4 g/day).

  • NSAIDs (e.g., ibuprofen, mefenamic acid): reduce prostaglandin levels, helpful for heavy bleeding and dysmenorrhea.

    • Ibuprofen: 400 mg orally every 6–8 hours with food.

    • Mefenamic acid: 500 mg orally every 8 hours during menstruation.

b) Hormonal Therapies

  • Combined Oral Contraceptives (COCs): regulate cycles, reduce endometrial proliferation.

    • Example: Ethinylestradiol 30 µg + levonorgestrel 150 µg daily for 21 days, followed by 7-day break.

  • Progestin therapy: induces regular shedding of endometrium.

    • Medroxyprogesterone acetate: 10 mg orally daily for 10–14 days per cycle.

    • Norethisterone: 5 mg orally 2–3 times daily for 10 days.

  • Levonorgestrel intrauterine system (LNG-IUS): highly effective, reduces bleeding by up to 95%.

    • Releases 20 µg/day levonorgestrel, lasts 5 years.

  • GnRH agonists (temporary use): suppress ovarian hormones, useful pre-surgery or in refractory cases.

    • Leuprolide acetate: 3.75 mg intramuscular monthly.

3. Surgical Management

a) Conservative Procedures

  • Endometrial ablation/resection: destroys endometrial lining, suitable for women who have completed childbearing.

  • Hysteroscopic polypectomy or myomectomy: for localized lesions.

b) Definitive Treatment

  • Hysterectomy: for severe cases not responsive to other treatments, especially in women who do not desire fertility.

Pharmacological Summary (Generic Names and Doses)

  • Tranexamic acid: 1 g orally 3–4 times/day during menstruation.

  • Ibuprofen: 400 mg orally every 6–8 hours with food.

  • Mefenamic acid: 500 mg orally every 8 hours during menstruation.

  • Ethinylestradiol + levonorgestrel: 30 µg/150 µg daily for 21 days, 7-day break.

  • Medroxyprogesterone acetate: 10 mg orally daily for 10–14 days per cycle.

  • Norethisterone: 5 mg orally 2–3 times daily × 10 days.

  • Levonorgestrel IUS (LNG-IUS): releases 20 µg/day, effective for 5 years.

  • Leuprolide acetate: 3.75 mg IM monthly.

  • Ferrous sulfate: 325 mg orally once/twice daily.

Complications of Heavy Periods

  • Iron-deficiency anemia: most common complication.

  • Severe fatigue and reduced quality of life.

  • Infertility: especially with fibroids, endometrial pathology, or PCOS.

  • Psychological distress: depression, anxiety, social withdrawal.

  • Surgical risks: in cases requiring hysterectomy or ablation.

Prognosis

  • Many cases resolve with medical therapy.

  • LNG-IUS is among the most effective non-surgical treatments.

  • Structural causes (fibroids, adenomyosis) may recur even after conservative surgery.

  • Endometrial carcinoma must be ruled out in women >45 years or with risk factors.

Preventive and Supportive Measures

  • Routine gynecological check-ups.

  • Early investigation of abnormal bleeding.

  • Screening for coagulation disorders in adolescents with menorrhagia.

  • Adequate iron intake.

  • Avoid unnecessary anticoagulant use unless medically indicated.




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