Menorrhagia (heavy periods)
Published by BUPA's Health Information Team
October 2003
Normal periods last three to seven days and involve a blood loss of about 4-12 teaspoonfuls (20-60ml). Some women have heavy periods (menorrhagia), which can be severe enough to cause anaemia (lack of red blood cells). Usually menorrhagia is not a sign of an underlying medical problem and can be easily treated.
What is defined as a heavy period?
Menorrhagia is defined as a loss of blood of more than 80ml, compared with the normal amount of 20-60ml. In practice, it's hard to measure the amount of blood lost during a period, so a period is defined as heavy if it leads to one or more of the following:
- frequent changes of sanitary towels (every two hours or more)
- the need to use double sanitary protection (tampons plus towels)
- passing large blood clots
- bleeding through to clothes or onto bedding at night - called "flooding"
- prevention of normal activities, such as going out, working or shopping
- anaemia - a shortage of red blood cells that can cause fatigue, dizziness and paleness.
Female reproductive organs
Causes
Usually menorrhagia is not due to an underlying medical problem. It is more common in women who are not ovulating, so it is particularly likely in women at the beginning or end of their reproductive life, ie in girls who have recently started having periods or in women approaching menopause.
However, sometimes there is an underlying cause, which can include:
- a hormone imbalance
- using an IUCD (intra-uterine contraceptive device)
- fibroids (benign lumps in the muscle wall of the uterus)
- endometriosis (areas of endometrial tissue growing outside the womb)
- infection of the vagina, cervix or uterus
- polyps (benign growths) on the cervix or uterus
- another abnormality of the lining of the uterus or cervix (neck of the womb), including cancer
- injury to the reproductive organs
- underactive thyroid, which causes weight gain, dry skin and lethargy as well as heavy periods
Diagnosis
Any woman who is concerned about excessively heavy bleeding should see her GP.
It's helpful to keep a record of the dates of periods and the times of any abnormal bleeding (bleeding other than a period), as well as a note of how heavy the periods have been (eg in terms of number of sanitary towels or tampons needed per day).
Women should check that bleeding is genuinely from the vagina and not the rectum. This may be caused, for example, by haemorrhoids (piles).
After listening to an account of the problem, the GP may carry out a pelvic (internal) examination, looking for signs of fibroids, endometriosis or polyps.
During a pelvic examination, the doctor will probably use a speculum, a device that is inserted into the vagina in order to view the cervix (neck of the womb). A cervical smear test ("Pap" smear) may be carried out at this point if you have not had one recently. The doctor will feel for any enlargement of the uterus and ovaries by pressing on the abdomen while feeling inside the vagina.
A blood sample may be taken to check for anaemia or abnormalities in the way blood is clotting, and to measure the levels of the hormones involved in regulating the menstrual cycle. For women who have not yet gone through the menopause, the timing of these blood tests is important and the doctor will explain the best time in the menstrual cycle to have them done.
If the doctor suspects an underactive thyroid, blood is also tested for this.
Further tests, such as an ultrasound scan of the pelvis (to view the uterus, Fallopian tubes and ovaries) may be recommended. This is usually done at a hospital outpatient clinic. It is a painless test that uses sound waves to create an image of the internal organs on a video monitor. A probe is moved across the surface of the abdomen. Clearer images can sometimes be produced with a special scanning probe that is placed into the vagina.
The GP may refer you to a gynaecologist - a doctor specialising in women's reproductive health. To get a direct view of the inside of the uterus, a gynaecologist may recommend a hysteroscopy. This uses a narrow flexible or rigid telescope called a hysteroscope, which is passed into the vagina, through the cervix and into the uterus. The lining of the womb (endometrium) can be closely inspected. If necessary, samples of tissue can be taken at the same time. These can be examined in a laboratory (biopsy) to check for abnormalities.
Treatments
If an underlying cause for the abnormal bleeding is identified, this needs to be treated. For example, infections can be treated with antibiotics. Fibroids and polyps can be removed surgically. If cancer is identified, it may be treated with chemotherapy, radiotherapy, surgery or a combination of these.
If no underlying medical problem is found, there are various treatment options for heavy periods.
Medicines
- The combined oral contraceptive pill (which combines oestrogen with a progestogen - a synthetic form of progesterone) is effective at reducing bleeding and making bleeding more regular. This is an option if the woman also wants contraception.
- Tranexamic acid (Cyklokapron) - this reduces bleeding by affecting how blood clots. If taken during a period, this can reduce the amount of bleeding by 50%. Side-effects can include nausea and leg cramps, and an increased risk of deep vein thrombosis (DVT; a blood clot, usually in the leg).
- Mefenamic acid (eg Ponstan) - this is a painkiller that also reduces bleeding. It's particularly beneficial if period pains are also a problem. It has fewer side-effects than tranexamic acid.
Progestogen-releasing IUCD
This intra-uterine contraceptive device (Mirena) releases levonorgestrel into the uterus. Levonorgestrel is a progestogen, a synthetic equivalent of the hormone progesterone, which reduces the amount of thickening that occurs in the lining of the womb before menstruation. It reduces or stops periods altogether. Like other coils, the Mirena coil is also a contraceptive.
Surgery
For women who have had all the children they want, surgery may be suggested. There are two options:
Endometrial ablation - also called trans-cervical resection of the endometrium (TCRE), this operation removes the lining of the uterus to a depth of about five or six millimetres. The surgeon uses a hysteroscope with special tools attached, or heat from an electric current or laser to remove the lining. It's usually carried out under a general anaesthetic. This tends to stop periods, and can be an alternative to hysterectomy.
Newer techniques of endometrial ablation can be performed under local anaesthetic at an outpatient clinic. These include using a balloon filled with hot water, extreme cold (cryotherapy) or microwave energy (microwave endometrial ablation; MEA) to destroy the endometrium.
After endometrial ablation, heavy periods may recur.
Hysterectomy - this is major surgery to remove the uterus. This is the only way to stop periods permanently. It may be suggested as a treatment for menorrhagia, and may be necessary if there is cancer or pre-cancerous growths in the uterus. In most cases the cervix is also removed. The operation is carried out under a general anaesthetic.
Further information
Related BUPA Factsheets
Common vaginal infections, Endometriosis, Fibroids, Hysterectomy, Hysteroscopy, Pelvic inflammatory disease, Polycystic ovarian syndrome
http://www.bupa.co.uk/health_information/
Women's Health
0845 125 5254
http://www.womenshealthlondon.org.uk
Women's Health UK
http://www.womens-health.co.uk
