Menstruation: Heavy Bleeding (Menorrhagia)
DescriptionAn in-depth report on the causes and treatment of heavy periods.
Alternative NamesBleeding: menstrual; Menstrual Disorders
It is often very difficult to diagnose true menorrhagia. For one, it is very difficult to measure blood loss during menstruation, and the perceptions of women as well as their physicians vary widely.
Some women may overestimate their menstrual flow. In one study 29% of women reporting menorrhagia had normal menstrual blood flow (less than about 2 ounces or 60 ml). In the study, such women tended to be anxious, unemployed, and also to have abdominal pain.
Some women underestimate it. For example, women with a family history of bleeding disorders might have menorrhagia but think it is normal because it is the same as their mother's or sister's.
Physicians may underestimate their patient's flow. In one study, comparing the perception of menstrual flow between physicians and patients, physicians believed that only 3.2% of their patients had menorrhagia while 53.7% of these patients self-reported the condition using an objective pictorial self-assessment chart.
A physician will perform a pelvic examination to check for pregnancy-related conditions and for signs of fibroids or other abnormalities, such as ovarian cysts.
Medical and Personal History
The physician needs to have a complete history of any medical or personal conditions that might be causing heavy bleeding. He or she may need the following information:
Keeping a Menstrual Diary. The patient can provide much of this information by keeping a diary of the amount of bleeding and pain that occurs over the course of two or three menstrual cycles is very helpful. One method is to track menstrual flow day by day by observing the pad or tampon. It uses a score of 1 to 20 to signify very light staining to extremely heavy staining. The diary would also use a scale for pain of 0 to 4 (no pain to severe pain).
Hysteroscopy is a procedure that may be used to detect the presence of fibroids, polyps, or other causes of bleeding. (It may miss cases of uterine cancer, however, and is not a substitute for more invasive procedures, such as D&C or endometrial biopsy, if cancer is suspected.)
It is done in the office setting and requires no incisions. The procedure uses a long flexible or rigid tube called a hysteroscope, which is inserted into the vagina and through the cervix to reach the uterus. A fiber optic light source and a tiny camera in the tube allow the physician to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This generally causes cramping.
Hysteroscopy is non-invasive, but 30% of women report severe pain with the procedure. The use of an anesthetic spray such as lidocaine may be highly effective in preventing pain from this procedure. Other complications include excessive fluid absorption, infection, and uterine perforation. Hysteroscopy is also employed as part of surgical procedures.
Ultrasound and Sonohysterography. Ultrasound is the standard imaging technique for evaluating the uterus and ovaries, detecting fibroids, ovarian cysts and tumors, and also obstructions in the urinary tract. It uses sound waves to produce an image of the organs and entails no risk and very little discomfort.
Transvaginal sonohysterography uses ultrasound along with saline infused into the uterus, which enhances the visualization of the uterus. This technique is proving to be more accurate than standard ultrasound in identifying potential problems. Some experts believe it should become a first line diagnostic tool for diagnosing heavy bleeding.
Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) gives a better image of any fibroids that might be causing bleeding, but it is expensive and not usually necessary.
Endometrial Biopsy With or Without Dilation and Curettage (D&C)
When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy can be performed in the office along with an ultrasound. It is usually used with a procedure called dilation and curettage (D&C), which is particularly important to rule out uterine (endometrial) cancer. A D&C is a somewhat invasive procedure:
The procedure is used to take samples of the tissue and to relieve heavy bleeding in some instances. D&C can also be effective in scraping off small endometrial polyps, but it is not very useful for most fibroids, which tend to be larger and more firmly attached.
Tests for bleeding disorders are important, particularly in very young women, before proceeding with invasive tests. Certainly blood testing for anemia is an important consideration in determining the need and type of treatment.