A woman will typically lose between 30 and 40ml of blood with her period, and usually over the course of four to eight days— but there is much variation. Definitions of heavy menstrual bleeding vary similarly, but in practice they refer to excessive bleeding that interferes with physical, emotional, social and material quality of life. Every woman’s experience is different, and some who have always had heavy periods might consider this normal. However, if you believe your experience is unusual, or your bleeding is excessive, there are many options for treatment.
What Causes Heavy Menstrual Bleeding?
Generally speaking, excessive bleeding can be a result of three main causes: hormones, changes within the uterus, and disorders of the blood. Some causes can be identified through tests and investigation, though in other cases there is no definite explanation. This is thought to be a disorder of blood clotting in the uterine lining, for which no test exists.
Hormonal imbalances are often associated with irregular periods, and can also affect the lining of the uterus. Common conditions include low thyroid activity, perimenopause, and polycystic ovarian syndrome (PCOS). Perimenopause refers to the time just before menopause when periods stop entirely, and PCOS refers to a disorder that causes enlarged ovaries with small external cysts.
Problems Relating to the Uterus
- The walls of the uterus can have muscular abnormalities that prevent proper contraction, and thus allow blood vessels to continue to bleed.
- Fibroids can also cause heavy menstrual bleeding, pelvic pain and fertility problems. Benign, non-cancerous growths, they can bulge from the inside or outside of the uterine muscle. They can range in size from microscopic to larger than a grapefruit and can be removed via surgery or medication. Fibroid symptoms tend to improve regardless after menopause.
- Uterine polyps may cause heavy bleeding during periods, between periods, or after intercourse. These are small, non-cancerous growths within the uterine lining, and can occasionally develop abnormalities— it is advisable to remove them, particularly in older women, before they become more harmful.
- Adenomyosis, where the lining of the uterus grows into the muscular wall, preventing adequate contraction of the muscle.
- Cancer or pre-cancerous changes in the uterine lining are rare (though serious) causes of heavy menstrual bleeding. Women are at an increased risk of developing these changes if they are over 45, over 90kg, have never had children have PCOS, or a familial history of cancer and its related genes.
Certain medical blood conditions, or medications can contribute to heavy menstrual bleeding. Common medications can include blood thinners like aspirin, hormone replacement treatments, and IUDs. Possible medical conditions include Von Willebrand Disease (which is inherited), and Pelvic Inflammatory Disease (which is caused by sexually transmitted infection).
Other uncommon causes can include some liver or kidney conditions, and occasionally contraceptives such as the Pill.
How Is Heavy Menstrual Bleeding Treated?
The first step to any treatment is often testing, to eliminate possible causes and suggest the best possible forms of treatment for your lifestyle and condition. You might encounter the following tests:
- Examination, where your doctor can examine the cervix to see if this is the source of the bleeding, rather than the uterus itself. This is performed in a similar way as a Pap smear or a screening test for HPV or cancer cells.
- Blood tests may be ordered to look for anaemia, iron levels, thyroid disease or a bleeding disorder.
- A vaginal ultrasound can be used to scan your ovaries and uterus to detect abnormalities such as polyps or fibroids.
- Internal swabs may be performed to exclude pelvic infection.
- A sample of the uterus’ lining might be taken in a biopsy, in order to determine if there are any cancerous changes.
- A hysteroscopy might be performed, using a narrow telescope to examine the inside of the uterus. This can be done awake or under anaesthetic; discuss which option works best for you with your doctor.
Treatments themselves are dependent on several factors, namely the cause of the bleeding and your desire for birth control or future children, among other medical concerns you might have. They can be divided into medical treatments and surgical options.
Medical Treatments for Heavy Menstrual Bleeding
Hormonal medical treatments mimic those in your body, through either a combination of oestrogen and progesterone, or progesterone alone. The most effective method is the IUD (intra-uterine device), which releases hormones into the local area of your uterine lining. It can stay in place for up to five years, and is very effective at reducing blood loss and preventing pregnancy. Oral contraceptives can also be used, and doctors might advise taking the Pill continuously without a break, which is perfectly safe. Other options include a vaginal ring, injections or skin patches.
Non-hormonal treatments aim to decrease blood flow and reduce cramping and pain. The most effective of these is tranexamic acid, a drug which allows blood to clot more effectively. In this way, it blocks the loss of blood from the uterus and reduces flow by approximately half— though it doesn’t reduce the number of days bleeding occurs. Anti-inflammatory painkillers such as ibuprofen can also reduce your flow by up to a quarter, though it similarly won’t reduce the length of time your period actually lasts.
Surgical Treatments for Heavy Menstrual Bleeding
Where medical treatment has been found to be ineffective, there are several surgical options:
- Polyps and small fibroids can also be removed at the time of a hysteroscopy.
- Laparoscopy can be used to remove large fibroids, or those in the wrong position. This is done through keyhole surgery or open surgery.
- Endometrial ablation, where heat is used to destroy the lining of the uterus. This can be done as a day procedure, and many women return to normal activity the next day. This option is only suitable if you don’t plan on becoming pregnant.
- A hysterectomy, or total removal of the uterus, is a permanent cure. Through keyhole, vaginal or abdominal surgery, this is likely only considered if this is your preferred treatment, or no other option has worked.
Regardless of your chosen treatments, discuss your bleeding and symptoms with your health professional. Heavy menstrual bleeding can have a profound negative impact on your quality of life, and by discussing this, your problems can be alleviated more quickly.