Living with Menorrhagia
(Heavy Menstrual Bleeding)

What is menorrhagia?

If you have menorrhagia, it means that you experience excessively heavy bleeding during your period (menstruation), or that you experience an unusually long menstrual period.

While heavy menstrual bleeding is a common concern, but most women do not experience blood loss severe enough to be defined as menorrhagia.

If you have menorrhagia, you may not be able to maintain your usual daily activities when you have your period.

How do you know if your period is too heavy?

Technically, menorrhagia is defined as menstrual bleeding where you need to change your tampon or pad after less than two hours, when you pass clots roughly the size of a five rand coin or larger during menstrual bleeding, or if you experience any menstrual bleeding for longer than seven days.

If you have menorrhagia you may also:

• Need to use double sanitary protection to control your menstrual flow.
• Need to wake up at night to change your sanitary protection.
• Have your daily activities restricted due to heavy menstrual flow.
• Experience symptoms of anaemia, such as pallor, fatigue or shortness of breath and dizziness or fainting.

What causes menorrhagia?

The menstrual cycle is regulated by hormones and should be a roughly regular process. The average menstrual cycle lasts around 28 days, but it can vary among individuals.

Each month (28 days), the outer uterine lining (the endometrium) thickens as it vascularises (builds up extra blood vessels and tissue) in preparation for the potential implantation of a fertilised egg (ovum).

While a fertilised egg will implant itself into the uterus and develop into a baby, an unfertilised egg, or a fertilised egg that does not implant, passes through the reproductive system. During menstruation hormone-like substances, called prostaglandins, cause the uterus to contract, shedding the endometrium through the vagina. This is known as menstruation, or your period.

In some cases, the cause of menorrhagia cannot be identified; however, in a number of cases, associated underlying conditions may be identified, including:

• Hormone imbalances: A balance between the hormones oestrogen and progesterone regulates the build-up and shedding of the endometrium during a normal menstrual cycle. If a hormone imbalance occurs, the endometrium can develop in excess and will need to eventually be shed through heavy menstrual bleeding. A number of conditions can cause hormone imbalances, including ovarian dysfunction, polycystic ovary syndrome (PCOS), obesity, insulin resistance and thyroid disease.
• Uterine fibroids: These are benign (non-cancerous) growths in the wall of the uterus that can cause heavy and abnormal menstrual bleeding.
• Uterine polyps: These are small, benign growths on the endometrium that may cause heavy or abnormal menstrual bleeding.
• Adenomyosis: This is a disorder where the tissue that lines the endometrium begins to grow into the uterine muscular wall (myometrium) beneath. This can cause heavy bleeding and dysmenorrhoea (painful menstrual cramps).
• The presence of an intrauterine device (IUD): The non-hormonal intrauterine device is a contraceptive for birth control that is known to cause menorrhagia as a side-effect.
• Miscarriage: A single, heavy and “late” period may be due to a miscarriage.
• Cancer: Uterine cancer and cervical cancer can cause excessive menstrual bleeding, especially if you are post-menopausal.
• Genetic/inherited bleeding disorders: Bleeding disorders, like von Willebrand’s disease, can result in important blood-clotting factors being deficient or impaired, causing heavy menstrual bleeding.
• Medications: Certain medications, including anti-inflammatory medications for pain relief, hormonal medications (such as oestrogen and progestins) and anticoagulants (like aspirin or warfarin), can cause menorrhagia.
• Other medical conditions: Other medical conditions, including liver or kidney disease, are associated with menorrhagia.

What is the treatment for menorrhagia?

If you are worried about getting your period each month, then talk to your doctor, as there is treatment available for menorrhagia, including:

• Pain relief: This is for the associated dysmenorrhoea and includes non-steroidal anti-inflammatories (NSAIDs). These medications may also help reduce menstrual flow.
• Tranexamic acid: This medication helps reduce menstrual blood flow and only needs to be taken during menstruation.
• Hormonal birth control/ “the pill”: Oral birth control tablets contain hormones that prevent ovulation (the release of an unfertilised egg from the uterus), thereby preventing pregnancy. These medications can also help regulate the menstrual cycle, reducing menorrhagia and the severity of period pain.
  These hormones can also be delivered in other contraceptive forms, such as an injection, skin patch, implant placed under the skin of your arm, a flexible ring that you insert into your vagina or by an intrauterine device (IUD).

Treating the underlying cause of your menorrhagia is important, such as getting treatment for thyroid disease.
If you have menorrhagia from taking hormone medication, you must talk to your doctor about changing or stopping your medication.

Additionally, if you also have anaemia due to heavy blood loss, your doctor may recommend that you take iron supplements regularly.

However, you may need surgery for treatment of menorrhagia if medication is unsuccessful.

Many of these procedures can be done on an outpatient basis; although you may need a general anaesthetic, it is likely that you can go home later on the same day. An abdominal myomectomy or a hysterectomy usually requires a hospital stay though.

Types of surgical procedures that can help treat causes of menorrhagia include:

• Dilation and curettage (D&C): In this very effective procedure, your doctor dilates (widens and opens) your cervix and then scrapes or suctions the endometrial tissue away to reduce menstrual bleeding. You may need additional D&C procedures if menorrhagia recurs.
• Uterine artery embolisation: If you have large fibroids causing menorrhagia, your doctor or healthcare provider can shrink the fibroids by blocking the uterine arteries, cutting off their blood supply.
• Focused ultrasound surgery: This procedure is similar to uterine artery embolisation. It involves using ultrasound waves to destroy fibroid tissue. There are no surgical incisions (or cuts) required for this procedure.
• Myomectomy: This is the surgical removal of uterine fibroids. Your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
• Hysterectomy: This is the surgical removal of your uterus and cervix. Hysterectomy is a permanent procedure that causes sterility (you can no longer fall pregnant) and ends menstruation. Hysterectomy is performed under anaesthesia and requires hospitalisation. This procedure may cause premature menopause.