Heavy Menstrual Bleeding

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What is heavy menstrual bleeding? – Menstrual bleeding is said to be heavy if it lasts longer than seven days or it soaks one or more menstrual pads fully every hour for several hours in a day or it comes with clots. Usually normal menstrual flow will last one to seven days but most commonly three to five days in the majority of women.

Most times, these women use one to two menstrual pads in a day, which are usually moderately soaked, although, it is usual for some women to change their menstrual pads more frequently for hygiene purposes despite not being soaked.

How common is heavy menstrual bleeding?

Heavy menstrual bleeding is common among women, affecting about one in three of women who are menstruating. 

What are the causes of heavy menstrual bleeding?

Heavy menstrual bleeding can be caused by factors localised to the uterus or those associated with the hormones controlling menstruation. 

Uterine causes:
  1. Uterine fibroids – These are abnormal masses in the uterus which may distort the contour of the uterus. Heavy menstrual bleeding due to fibroid depends on its location within the uterus. Those located close to the inner part of the uterus or inside the muscle may cause heavy uterine bleeding.
  2. Adenomyosis – This represents abnormal tissues within the uterine muscles. These tissues prevent the uterine muscles from contracting well in order to limit blood loss during menstruation. 
  3. Uterine polyps – These are fleshy-like tissues arising from the inner aspect of the uterus. It distorts the inner lining of the uterus and thereby causes heavy menstrual flow.
Hormonal causes:
  1. Infrequent ovulation – When ovulation fails to occur a particular cycle, endometrial maturation is prolonged due to low level of progesterone compared to oestrogen. The endometrial layer continues to grow until it overgrows its blood supply. At this point, it begins to shed. Due to the excessive growth, it may shed for a prolonged time and may be heavy. 
  2. Hormonal family planning methods – Some family planning methods containing progesterone such as implant or those contained in injections can result in heavy menstrual flow. Their actions lead to uneven development of the uterine lining which subsequently leads to uneven and prolonged shedding.
Non-hormonal causes
  1. Non-hormonal intrauterine contraceptive device – This acts as a foreign body inside the uterus; and as such, the uterus attempts to push it out with more forceful contraction which results in more pain and bleeding than usual. This may subside after some months. 
  2. Pelvic inflammatory disease – This is an infection of the reproductive organs of women. It affects, among other areas, the lining of the uterus. This interferes with the normal shedding of the uterine lining, resulting in heavy menstrual bleeding.
  3. Bleeding disorder – This may be inherited or acquired. This disorder prevents blood from clotting and thereby leaves the surfaces of the blood vessels on the uterine lining exposed for too long.
  4. Drugs – Some drugs that have impact on the ability of blood to clot (such as warfarin, heparin, aspirin etc) may result in heavy menstrual bleeding as blood clotting plays a significant role in limiting the blood loss during menstruation.
  5. Liver disease – This may prevent the ability of the liver to produce clotting factors. Their deficiency alters the ability of blood to clot, leading to excess menstrual blood loss.
  6. Thyroid disease – Thyroid hormones regulate many body functions including menstruation. Elevation or reduction in value can result in heavy menstrual bleeding.
  7. Cancers – Cancer of the uterus and ovaries can lead to heavy menstrual flow due to overgrowth of the uterine lining whereas cervical cancer may cause heavy menstrual bleeding and bleeding in-between periods due to the wounds created by the cancer as it eats into the tissues.

What is the treatment for heavy menstrual bleeding?

The treatment of heavy menstrual bleeding depends on the cause. This may include:

  1. Oral contraceptive pills – These contain the primary hormones that regulate menstruation: oestrogen and progesterone, in low doses. They are mostly used for birth control but can be employed to regulate menses and reduce menstrual flow.
  2. Drugs that promote blood clot formation – Tranexamic acid is useful in this regard. Blood clotting helps to seal the bleeding surfaces in the uterus and minimise blood loss.
  3. Hormonal Intrauterine contraceptive device – This contains the hormone progesterone which helps in the maturation of the endometrial lining and thus encourages uniform shedding of the lining and moderate menstrual flow.
  4. Treatment of underlying diseases – Disease that interferes with smooth regulation of menstrual flow such as thyroid disease, uterine fibroids, polyps, etc should be treated. Hormonal contraception causing heavy bleeding may be discontinued.
  5. Replacement of the blood loss – Sometimes, blood transfusion may be necessary if blood loss is massive or drugs that stimulate blood production used in cases where the blood loss is not too massive.
  6. Surgical intervention – Some surgical interventions may be necessary if medical treatments do not control heavy menstrual bleeding. These include: dilatation and curettage (to remove the lining of the uterus, from where menses comes from), blocking the blood vessels that connect to the uterus, removal of fibroid, polyps or complete removal of the uterus.
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