What is period?

Menstruation( Periods) is the periodic discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. A normal period is a blood loss between 20 and 60 ml (4-12 teaspoonfuls). Bleeding can last up to eight days, but bleeding for five days is average A heavy period is a blood loss of 60-80 ml or more. This is about half a teacupful or more. However, it is difficult to measure the amount of blood that you lose during a period. For practical purposes, a period is probably heavy if it causes one or more of the following:

  • Flooding through to clothes or bedding.
  • Frequent changes of sanitary towels or tampons.
  • Double sanitary protection (tampons and towels).
  • Pass large blood clots.

Menorrhagia means heavy periods that recur each month. Also, that the blood loss interferes with your quality of life. For example, if it stops you doing normal activities such as going out, working or shopping. Menorrhagia can occur alone or in combination with other symptoms.

Dysfunctional uterine bleeding- cause is not known and is the cause of heavy periods in 4 to 6 out of 10 cases. In this condition, the womb (uterus) and ovaries are normal. It is not an hormonal problem. Ovulation is often normal and the periods are usually regular. It is more common in recently started your periods or approaching the menopause. Other causes These are less common. They include the following:

  • Fibroids. These are benign (non-cancerous) growths in the muscle of the uterus. They often cause no problems, but sometimes cause symptoms such as heavy periods.
  • Other conditions of the uterus, such as endometriosis , infections or polyps, may lead to heavy periods. Cancer of the lining of the uterus endometrial cancer is a very rare cause. Most cases of endometrial cancer develop in women aged in their 50s or 60s.
  • Hormonal problems. Periods can be irregular and sometimes heavy if not ovulate every month. For example, this occurs in some women with polycystic overy syndrome. Women with an low thyroid home may have heavy periods.
  • The intrauterine contraceptive device (IUCD, or coil) sometimes causes heavy periods. However, a special hormone-releasing IUCD called the intrauterine system (IUS) can actually treat heavy periods
  • Pelvic infections. There are different infections that can sometimes lead to heavy bleeding developing. For example, chlamydia can occasionally cause heavy bleeding. These infections can easily be treated with antibiotics.
  • Warfarin or similar medicines interfere with blood clotting.
  • Some drugs used for chemotherapy can also cause heavy periods.
  • Blood clotting disorders are rare causes of heavy bleeding.

Do I need any tests if I have heavy periods?

  • A doctor may want to do an internal (vaginal) examination to examine your neck of the womb (cervix) and also to assess the size and shape of your womb (uterus). However, an examination is not always necessary, especially in younger women who do not have any symptoms to suggest anything other than dysfunctional uterine bleeding.
  • A blood test to check for anemia is usually performed. If bleed heavily each month then may not take in enough iron in your diet, needed to replace the blood loss

If the vaginal examination is normal (as it is in most cases), and patient are under the age of 40, no further tests are usually needed. The diagnosis is usually dysfunctional uterine bleeding and treatment may be started if required. Further tests may be advised for some women, especially if there is concern that there may be a cause for the heavy periods other than dysfunctional uterine bleeding. For example:

  • Women over the age of 45 who develop heavy periods.
  • If treatment for presumed dysfunctional uterine bleeding does not seem to help.
  • Any woman where a doctor detects a large or abnormal uterus, or who has other symptoms which may indicate an underlying problem. For example, if you:
    • Bleed between periods, or have irregular bleeding.
    • Have bleeding or pain during, or just after, sex.
    • Have pain apart from normal period pains.
    • Have any change in your usual pattern of bleeding, particularly if you are over the age of 45.
    • Have symptoms suggesting an hormonal problem or blood disorder.

If tests are advised then they may include one or more of the following:

  • An ultrasound scan of uterus. This is a painless test which uses sound waves to create images of structures inside your body. The probe of the scanner may be placed on your tummy (abdomen) to scan the uterus. A small probe is also often placed inside the vagina to scan the uterus from this angle. An ultrasound scan can usually detect any fibroids, polyps, or other changes in the structure of your uterus.
  • Internal swabs. This may be done if an infection is the suspected cause of the heavy bleeding. A swab is a small ball of cotton wool on the end of a thin stick. It can be gently rubbed in various places to obtain a sample of mucus, discharge, or some cells. A swab is usually taken from the top of vagina and also from your cervix. The samples are then sent away to the laboratory for testing.
  • Endometrial sampling. This is where a thin tube is passed into the uterus. Gentle suction is used to obtain small samples (biopsies) of the uterine lining (endometrium). This is usually done without an anaesthetic. This is more likely to be done if you are aged over 45 years, have persistent bleeding or have tried treatment without it helping. The samples are looked at under the microscope for abnormalities.
  • Hysterescopy-This is used to look inside the uterus. A thin telescope is passed into uterus through your cervix via the vagina. This too can often be done without an anaesthetic. Small samples can also be taken during this test.
  • Blood tests. For example, if an underactive thyroid gland or a bleeding disorder is suspected.

Treatment aims to reduce the amount of blood loss. The treatment here discussed mainly for women who have regular but heavy periods with no clear cause (dysfunctional uterine bleeding). This is the majority of cases. If there is an underlying cause, such as a fibroid or endometriosis, treatment options may be different.

Not treating

This is an option if your periods do not interfere too much with normal life. You may be reassured that there is no serious cause for your heavy periods, and you may be able to live with them. A blood test may be advised every so often to check for anaemia. Iron tablets can correct anaemia.

Levonorgestrel intrauterine system (LNG-IUS)

This treatment usually works very well. The LNG-IUS (or Mirena© coil) is similar to an intrauterine contraceptive device (IUCD, or coil). It is inserted into the womb (uterus) and slowly releases a small amount of a progestogen hormone called levonorgestrel. The amount of hormone released each day is tiny but sufficient to work inside the uterus. In most women, bleeding becomes either very light or stops altogether within 3-6 months of starting this treatment. Period pain is usually reduced too. The LNG-IUS works mainly by making the lining of the uterus very thin. The LNG-IUS is a long-acting treatment. Each device lasts for five years, although it can be taken out at any time. It is particularly useful for women who require long-term contraception, as it is also a reliable form of contraception. This is, however, not usually suitable if you do not need long-term (for at least one year) contraception.

Tranexamic acid tablets-

Treatment with tranexamic acid can reduce the heaviness of bleeding by almost half (40-50%) in most cases. However, the number of days of bleeding during a period is not reduced, and neither is period pain. You need to take a tablet 3-4 times a day, for 3-5 days during each period. Tranexamic acid works by reducing the breakdown of blood clots in the uterus. In effect, it strengthens the blood clots in the lining of the uterus, which leads to less bleeding. If side-effects occur they are usually minor, but may include an upset stomach.

Anti-inflammatory painkillers

There are various types and brands. Most are available only on prescription but you can buy one called ibuprofen from pharmacies. Your doctor may prescribe ones called mefenemic acid or Naproxyn. These medicines reduce the blood loss by about a third (20-50%) in most cases. They also ease period pain. You need to take the tablets for a few days during each period. They work by reducing the high level of prostaglandin in the lining of the uterus  which seems to contribute to heavy periods and period pain. However, they do not reduce the number of days the period lasts.

The combined oral contraceptive pill (COCP)

This reduces bleeding by at least a third in most women. It often helps with period pain too. It is a popular treatment with women who also want contraception, but who do not want to use the LNG-IUS. If required, you can take this in addition to anti-inflammatory painkillers (described above), particularly if period pain is a problem.

Long-acting progestogen contraceptives

The contraceptive injection and the contraceptive implant also tend to reduce heavy periods. For example, up to half of women on the contraceptive injection have no periods after a year. They are not given as a treatment just for heavy periods. However, if you require contraception then one of these may be an option for you.

Norethisterone

This is a progestogen medicine. It is not commonly used to treat heavy periods. It is sometimes considered if other treatments have not worked, are unsuitable or are not wanted. Norethisterone is given to take on days 5-26 of your menstrual cycle (day 1 is the first day of your period). However, taking norethisterone in this way does not act as a contraceptive. The reason why norethisterone is not commonly used as a regular treatment is because many women get side-effects, such as bloating, fluid retention, breast tenderness, nausea, headache and dizziness. However, norethisterone is used as a temporary measure to stop very heavy menstrual bleeding

Other medicines

Other hormonal treatments, such as gonadotrophin-releasing hormone (GnRH) analogues, are occasionally used by specialists in hospital. However, they are not routine treatments, due to various side-effects that commonly occur.

Surgical treatment

Having surgery is not a first-line treatment. It is an option if the above treatments do not help or are unsuitable:

  • Removing or destroying the lining of the uterus is an option. This is called endometrial ablation or resection. An instrument is passed into the uterus via the vagina. The aim is to remove as much of the lining of the uterus as possible. This can be done in various ways such as by using heat, microwaves, and cryotherapy. This treatment prevents women from having children in the future.
  • Hysterectomy- is the traditional operation where the uterus is totally removed. However, hysterectomy is done much less commonly these days since endometrial ablation became available in the 1990s. It may be considered if all other treatment options have not worked for you.