What Does Heavy Menstrual Bleeding Mean?
Because of the lack of discussion and education around this topic, many women do not know what may constitute heavy menstrual bleeding versus normal menstrual bleeding. I know that for me, as an adolescent, I assumed it was normal to have to double up on tampons and pads, to need a bathroom every hour or two during my period, to get up several times at night to change tampons and pads, and to always have a change of clothes with me. It wasn’t until I had been seriously anemic for many years that I started to question what I had been told up to that point even by doctors, which was that my heavy periods were normal. We need better menstrual education for teens, so that problems like heavy menstrual bleeding and other women’s health issues can be diagnosed earlier.
The medical definition of heavy menstrual bleeding, also known as menorrhagia, is bleeding that is abnormally heavy (more than 80 mL of blood per period), abnormally prolonged (more than 7 days of bleeding), or both. However, even knowing the medical definition of heavy menstrual bleeding does not necessarily help women identify whether or not their bleeding is normal, because translating that number into what they are experiencing with their menstrual cycle is quite difficult.
Most women probably assume that most or all of the menstrual fluid is blood, but actually on average, only about 36 percent of the fluid is blood. And this percentage varies widely among women, from 1.6 percent to 81 percent. The guideline typically used is that bleeding that soaks through a large pad or tampon in under two hours, going on for several hours, or with large clots, is too heavy. But even among brands of pads and tampons the absorbency can vary from less than 1 mL to almost 100 mL. Because of the difficulty in quantifying bleeding, in many cases doctors will use a woman’s subjective description of her heavy menstrual bleeding as an indication that there is a problem that needs treatment. In some cases this will result in unnecessary treatment for a problem that does not really exist.
Causes of Heavy Menstrual Bleeding
When considering the possible causes of heavy menstrual bleeding, it is important to remember that heavy menstrual bleeding can result from gynecological causes, as well as hematological causes (bleeding disorders). Usually when a woman presents to her doctor with heavy menstrual bleeding, she will be referred to a gynecologist, resulting in an investigation of gynecological causes. However, even when the gynecological investigation does not provide answers as to the cause of the bleeding, hematological causes are not typically investigated. In approximately 50 percent of cases of heavy menstrual bleeding, no cause is found.
Gynecological causes of heavy menstrual bleeding include hormone imbalances, dysfunction of the ovaries, uterine fibroids or polyps, adenomyosis, pelvic inflammatory disease, and in rare cases, cancer. Hematological causes include inherited bleeding disorders such as von Willebrand disease, platelet function disorders, hemophilia A and B, or other clotting factor deficiencies. Bleeding disorders have traditionally been highly under recognized in women, and still are, and some, such as von Willebrand disease, can be hard to diagnose. After gynecological issues are ruled out as a possible cause of heavy menstrual bleeding, it may be important to investigate hematological causes, especially if there are any other bleeding symptoms such as nosebleeds, or abnormal bleeding with dental work or surgeries.
Treatment of Heavy Menstrual Bleeding
Although there are treatments for heavy menstrual bleeding, unfortunately in many cases they are not effective enough. Sixty percent of women referred to a gynecologist for heavy menstrual bleeding will have a hysterectomy within the five years following the referral. Many of these hysterectomies may not be necessary—in some cases gynecological causes are not being treated effectively enough, or bleeding disorders are not being identified.
If a cause can be identified for the bleeding, treating the root cause, in most cases, is preferable. However, there are also treatment options that can address heavy bleeding regardless of the root cause, and the effectiveness and potential side effects of these options varies. There are non-specific treatments such as hormonal contraceptives and non-steroidal anti-inflammatory medications that are often used for a variety of women’s health conditions, and for some women, these can reduce heavy menstrual bleeding as well. There are also two treatments specifically used for heavy menstrual bleeding that can be fairly effective, but each comes with its own risks. Lysteda (tranexamic acid) is an oral medication used as needed during menstruation, and endometrial ablation is a surgical treatment option.
This medication has been used to prevent and treat blood loss in a variety of situations, such as in trauma cases, surgeries with heavy blood loss, and patients with bleeding disorders. In 2009, it was approved as an oral medication to treat heavy menstrual bleeding. This medication works by slowing the breakdown of blood clots, helping to prevent heavy bleeding, and is used when needed during menstrual periods. It can be used for heavy menstrual bleeding from a variety of different causes, both gynecological, and hematological.
A review of multiple studies of the effectiveness of Lysteda concluded that it can reduce menstrual blood loss by up to 50 percent, and that use of Lysteda results in improved quality of life for patients. No significant side effects were seen observed in these studies. However, since Lysteda affects the blood clotting pathway, there is the potential for increased risk of thromboembolism (obstruction of a blood vessel by a blood clot), although studies to date have not shown any increased risk. This medication should not be used in women with active thromboembolism, or in those with history of or at risk of thromboembolism.
Endometrial Ablation Surgery
Another treatment that is used specifically for heavy menstrual bleeding is endometrial ablation. This is a procedure that surgically destroys the lining of the uterus. The surgery is minimally invasive, requiring no incisions—it is done through the vagina and cervix. In some cases, it can even be done in a doctor’s office, depending upon the method used and the patient characteristics. This treatment is usually used once other less invasive options have failed. However, pregnancy after endometrial ablation can have serious complication, so endometrial ablation is only recommended for women who do not plan to become pregnant.
Endometrial ablation is considered a fairly effective treatment for heavy menstrual bleeding. Depending on the method used, 28 to 71 percent of women will have no menstrual bleeding at all after ablation. Patient satisfaction for all methods is 89 percent or higher. However, about one in six women will require further surgery after endometrial ablation. Hysterectomy is the most common surgery after endometrial ablation, and some women will have a repeat endometrial ablation. Further surgery after ablation is considered a “treatment failure” and can result from continued bleeding, pain, or both. Younger age at the time of the procedure is associated with a higher risk of treatment failure.
Although the procedure itself has been shown to be safe and have a relatively low risk of complications, it is also well recognized that pelvic pain can develop or worsen after endometrial ablation. Longer term complications specifically related to ablation include painful obstructed menstruation, hemometra (retention of blood in the uterus), and post-ablation tubal sterilization syndrome, which is a painful condition that can develop in patients who have had both tubal sterilization and endometrial ablation. About 21 percent of patients have pelvic pain following endometrial ablation. Risk factors for treatment failure with endometrial ablation, in addition to younger age, include painful periods prior to the surgery, endometriosis, adenomyosis, prior tubal ligation, and in some studies, obesity. Endometrial ablation has been used in a wider and wider group of women since its introduction; however, now that risk factors for treatment failure are better understood, women and their doctors can make a better informed decision about whether this procedure would be right for them.
Like many other women’s health issues, heavy menstrual bleeding is a problem that affects many women in significant ways, but is rarely discussed. Many women just put up with it for years or even a lifetime without seeking help. Removing the stigma from discussions about menstrual problems will help many women have a better quality of life and may lead to better treatment options than those currently available.
This post was published originally on Hormones Matter on November 23, 2015.
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