Understanding Menorrhagia (Heavy Menstrual Bleeding) And Its Implications

Menorrhagia (Heavy menstrual bleeding) may be common, but they are not normal and should not be ignored. While it can be caused by benign conditions such as hormonal imbalances or fibroids, menorrhagia can significantly disrupt daily life and lead to complications like iron deficiency anaemia. In some cases, it may be due to more serious medical conditions, such as endometrial cancer. This article explores the causes and treatment options related to menorrhagia and when you should consult a gynaecologist.

What Is Menorrhagia?

Menorrhagia was once defined as a monthly blood loss exceeding 80 ml. This was assessed by weighing soiled sanitary pads. Modern definitions focus on the patient’s symptoms. Any menstrual bleeding that results in an impairment of a woman's quality of life is considered abnormal.

A typical menstrual flow lasts up to seven days and, typically, should not cause you to soak pads every hour or overflow. Menorrhagia can occur at any stage of the reproductive cycle. It is most common soon after menarche and in the 40s, when hormonal changes occur and benign uterine growths tend to appear.

When Should You See a Gynaecologist?

A menstrual flow is considered abnormal when its volume or duration regularly overwhelms standard sanitary protection or causes physical symptoms.

• You need to use both a pad and a tampon or get up at night to change protection.

• Your flow contains large blood clots and may even cause pain.

• You feel fatigued, giddy or short of breath, which are signs of anaemia.

• Cramps and bleeding regularly stop you from work, school or social activities.

If any of these situations sound familiar, you should schedule a gynaecology appointment rather than wait for the next cycle.

What Causes Menorrhagia?

Menorrhagia can be caused by:

• Hormonal imbalance: When there is an imbalance of your oestrogen and progesterone levels, the endometrial lining can become abnormally thickened. When it sheds to become menstruation, it may be heavier than usual.

• Uterine fibroids or polyps: These growths are usually benign. However, they can increase the surface area of the endometrial cavity, resulting in heavier and prolonged periods.

• Bleeding disorders: Genetic conditions such as von Willebrand disease can prevent blood from clotting properly, resulting in prolonged and heavy bleeding.

• Adenomyosis: Endometrial tissues can be implanted into the muscular wall of the uterus, resulting in heavier and more painful periods.

• Medications: Medications that thin the blood (such as Aspirin, Clopidrel, Heparin and Warfarin) and hormone pills (such as oestrogen) can make menstrual bleeding heavier and prolonged.

• Copper IUDs: The copper IUD is known to cause heavier and painful menstruation during the first few cycles following insertion.

• Thyroid disorders: An underactive thyroid reduces the body’s metabolism and can result in prolonged menstruation.

• Pelvic Cancer: Though rare, cancer of the uterus or cervix can cause sudden, unexpected and heavy bleeding.

How Menorrhagia Is Investigated

During your first visit, you can expect your gynaecologist to take a detailed medical history. 

You can expect specific questions on:

• Cycle details: Cycle length, duration of bleeding, how heavy the flow is and the presence of blood clots, and abnormal bleeding patterns such as intermenstrual bleeding, and bleeding associated with sexual intercourse.

• Symptoms: Whether you had pain, including its intensity, frequency and duration, dizziness, fatigue, or shortness of breath.

• Medication use: Use of hormonal medications, including contraceptive pills, blood thinners, copper IUD or Mirena device.

• Personal and family history: Thyroid conditions, bleeding disorders, fibroids, or gynaecological cancers.

• Impact on Lifestyle/Quality of Life: Whether you have missed work, school or social activities or suffer sleep disruption due to menorrhagia.

The following investigations may also be performed:

• Pelvic examination: To look for cervical growth, signs of infection, or an enlarged uterus (adenomyosis).

• Blood tests: To check for anaemia, thyroid and clotting disorders and hormonal imbalances.

• Pelvic ultrasound: To assess for adenomyosis, fibroids, endometrial polyps, or thickened endometrium.

• Hysteroscopy, dilatation and curettage: A day surgery procedure which is performed under sedation or general anaesthesia. A camera connected to a scope is passed through the cervix into the uterus to inspect the endometrial cavity directly. This allows for sampling of the endometrium and removal of polyps or fibroids during the same setting.

Treatment options for menorrhagia

Treatment for menorrhagia often overlaps with treatment for dysmenorrhoea (painful periods) and involves relieving both excessive period flow and cramps at the same time.

Non-hormonal medications are taken specifically during your period. It does not affect your hormone levels and fertility aspirations.

• Tranexamic acid: An antifibrinolytic medicine that stops the body from breaking down clots too quickly, keeping them stable and noticeably reducing menstrual bleeding.

• NSAIDs: They can reduce blood loss by up to 35%, and are also used in the treatment of dysmenorrhoea. 

Hormonal therapy adjusts oestrogen and progesterone levels so that the endometrial lining remains thin and the period remains manageable.

• Birth control pills: Combined oral contraceptives contain estrogen and progestin, which suppress ovulation and stabilise the endometrial lining. This results in a thinner endometrial lining that sheds less blood during menstruation. 

• Mirena (Hormonal IUDs): Releases a small, steady dose of a hormone called levonorgestrel inside the endometrial cavity. This hormone thins the endometrium. As there is less tissue to shed, the periods become shorter and lighter.

Surgery can be considered when pelvic scans show a structural problem or if the above medicines fail to stop the menorrhagia.