Dr. Amy Banulis is a board-certified ob-gyn with the Mid-Atlantic Permanente Medical Group. She sees patients at the Kaiser Permanente Falls Church Medical Center.
Most women don’t exactly look forward to their monthly period. They don’t want to grapple with cramps, headaches, or feminine hygiene products.
While for most women having a period is a nuisance, for some it is a significant medical concern. Some women may experience bleeding so heavy that it interferes with going to work or school and may develop symptoms of anemia, such as feeling tired. Unfortunately, heavy menstrual bleeding is very common. According to the U.S. Centers for Disease Control and Prevention, heavy menstrual bleeding — also called menorrhagia — affects 10 million women each year. That is equivalent to one in every five women in the United States.
As an ob-gyn, I encourage women to talk to their doctors if they are experiencing heavy menstrual periods. We often can figure out the cause of the problem and then develop a treatment plan that could include lifestyle changes, medication, or surgery.
What is Heavy Menstrual Bleeding?
Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman’s physical, social, or emotional quality of life.
Any of the following can be a sign of heavy menstrual bleeding:
- Bleeding that lasts more than seven days. Menstruation usually lasts seven days, though some women may bleed for fewer. We become concerned when women bleed for eight days or longer.
- Bleeding that soaks through one or more tampons or pads every hour for several hours in a row.
- Needing to wear more than one pad at a time to control menstrual flow.
- Needing to change pads or tampons during the night.
- Blood clots that are as big as a quarter or larger.
Women who experience heavy menstrual bleeding may experience uncomfortable cramps.
Teens who have recently begun menstruating may have heavy periods followed by a few months of no periods at all. These irregular periods usually are not a sign of a medical condition that needs to be treated. Teen periods usually become more regular within about two years of starting menstruation.
What are the Causes of Heavy Menstrual Bleeding?
Heavy menstrual bleeding may be a sign of an underlying health problem that needs treatment. Some of the causes include the following:
- Fibroids and polyps. Uterine fibroids are benign growths in the uterus or womb. They are not cancerous. Fibroids are very common: Up to 75 percent of women will have at least one uterine fibroid at some point in her life. They are usually small and don’t cause symptoms, but large ones can cause heavy periods. July is Fibroid Awareness Month, a great time to learn more about this common condition.
- Adenomyosis. This is a condition where cells that normally line the uterus grow into the wall of the uterus.
- Irregular ovulation. Areas of the endometrium (the lining of the uterus) can become too thick in those who do not ovulate regularly. This condition is common during puberty and perimenopause, the years before menopause. It also can occur in women with certain medical conditions, such as polycystic ovary syndrome and hypothyroidism.
- Bleeding disorders, such as Von Willebrand disease. This is a rare bleeding disorder in which the blood does not clot properly. It is usually diagnosed in the teenage years.
- Medications. Blood thinners and aspirin can cause heavy menstrual bleeding.
- Some birth control methods. The copper intrauterine device can cause heavier menstrual bleeding, especially during the first year of use, however, it is unlikely to cause enough bleeding to lead to anemia or other health problems.
- Cancer. Heavy menstrual bleeding can be an early sign of endometrial cancer, a type of uterine cancer. Most cases of endometrial cancer are diagnosed in women in their mid-60s who are post-menopausal. It often is diagnosed at an early stage when treatment is the most effective.
Sometimes, the cause of heavy menstrual bleeding is not known.
Heavy Menstrual Periods and Anemia
Blood loss from heavy periods can lead to a condition called iron-deficiency anemia. Anemia can lead to fatigue. Severe anemia can cause shortness of breath and increase the risk of heart problems. It’s important to treat anemia from heavy menstrual bleeding.
Treatment may include iron supplements and/or a diet that includes iron-rich foods, such as lentils; beans; chickpeas; nuts; eggs; lean meats; dark, leafy greens; fortified breads; and cereals.
Talking to the Doctor About Heavy Menstrual Periods
When you see your ob-gyn about heavy menstrual bleeding, you may be asked about:
- Past and present illnesses and surgical procedures;
- Pregnancy history;
- Medications, including those you buy over the counter;
- Your birth control method;
- Your menstrual cycle. Try to use a calendar to keep track of when your period starts each month and how long it lasts. Note the amount of blood flow: spotting, light, medium, or heavy. Try to keep a log for several cycles to help your doctor detect patterns. A normal menstrual cycle lasts from 21–35 days, with approximately five to seven days of bleeding. The first day of the menstrual cycle is the day you start bleeding. The cycle ends on the first day of your next period.
You may have a physical exam, including a pelvic exam. Several lab tests may be done. You may have a pregnancy test and tests for some sexually transmitted infections. Based on your symptoms and your age, additional tests may be needed.
The additional tests your doctor may order include the following:
- Ultrasound exam. This painless exam looks for fibroids, polyps, or ovarian cysts.
- Hysteroscopy. A thin, lighted scope is inserted into the uterus through the opening of the cervix, allowing the doctor to see inside the uterus.
- Endometrial biopsy. A sample of the endometrium is removed and examined under a microscope. Sometimes hysteroscopy is used to guide this test. A surgical procedure called dilation and curettage is another way this test can be done.
- Sonohysterography. Fluid is placed in the uterus through a thin tube while ultrasound images are made of the uterus.
- Magnetic resonance imaging. This test views internal organs and structures using a strong magnetic field and sound waves.
Treating Heavy Periods
I encourage women to talk to their doctors about anything they consider abnormal about their menstrual cycles, including heavy bleeding. We have medications and surgical procedures that can lighten flow and help improve quality of life. For some women who have anovulatory bleeding due to polycystic ovary syndrome or other conditions, weight loss alone can help reduce menstrual flow.
For most women, we usually try medications first. Heavy bleeding caused by problems with ovulation, endometriosis, polycystic ovary syndrome or fibroids often can be managed with hormonal birth control methods. Hormonal birth control can lighten menstrual flow, make periods more regular, or even stop bleeding completely.
Hormone therapy can be helpful for heavy menstrual bleeding that occurs during perimenopause. But before deciding to use hormone therapy, talk to your doctor about the benefits and risks, such as a possible increased risk of heart attack, stroke, and some cancers.
Gonadotropin-releasing hormone agonists stop the menstrual cycle and reduce the size of fibroids. Their effect on fibroids is temporary. Once you stop taking a GnRH agonist, fibroids may return to their original size.
Tranexamic acid is a prescription medication that treats heavy menstrual bleeding. It is typically taken for five days starting with the first day of your period.
Nonsteroidal anti-inflammatory drugs, such as ibuprofen, may help control heavy bleeding and relieve menstrual cramps. If you have a bleeding disorder, your treatment may include special medications to help your blood clot.
Some women benefit from surgical procedures. Endometrial ablation destroys the lining of the uterus. It stops or reduces menstrual bleeding. Endometrial ablation can be performed in the ob-gyn’s office. The procedure takes less than 30 minutes and has a short recovery time. Pregnancy is not likely after ablation, but it can happen. If it does, the risk of serious complications is greatly increased, therefore, this procedure is not recommended for anyone planning pregnancy in the future. You will need to use a birth control method until after menopause following endometrial ablation. Sterilization (permanent birth control) may be a good option to prevent pregnancy for women who have had endometrial ablation.
Uterine artery embolization is used to treat large fibroids. In UAE, the blood vessels to the fibroids are blocked, stopping the blood flow that allows fibroids to grow. The minimally invasive procedure is performed by an interventional radiologist.
Other procedures include myomectomy, a surgery to remove large fibroids without removing the uterus; hysteroscopy, a minimally invasive procedure to remove small fibroids and polyps in the lining of the uterus; and hysterectomy, which is surgical removal of the uterus. Hysterectomy is used to treat fibroids and adenomyosis when other treatments haven’t worked or aren’t an option. After the uterus is removed, a woman will no longer have periods and can no longer get pregnant.
Most of the time, we can find a cause of heavy menstrual bleeding and treat the underlying issue. Even if we can’t find the cause, there are still options to make periods lighter so that you can get back to enjoying activities without worrying about life getting interrupted by heavy bleeding.
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