Menstruation or periods are a woman's normal monthly physiological bleeding. Every month, a woman's body prepares for pregnancy. If no pregnancy occurs, the womb sheds its inner lining. The menstrual blood is partly blood and partly tissue from inside the uterus or womb.
Periods start at puberty (any time between ages eight and 16) and continue until menopause (late 40s to early 50s). Generally, a woman's period lasts from three to five days.
For some women, this is a time no different from any other, and they get through their monthly periods easily, with few or no concerns. However, for some others, this can be a time she has to put her life on hold as she deals with a host of physical and/or emotional symptoms just before and during menstruation.
Is heavy menstrual bleeding really a problem?
Heavy menstrual bleeding, also known as menorrhagia, is a key cause of ill health in women. It is estimated that 9-30 per cent of women of reproductive age suffer from heavy menstrual bleeding, with the prevalence increasing with age, and peaking just prior to menopause.
Heavy menstrual bleeding has such an impact on women's lives that one in 20 women aged 30-49 years consult their general practitioners on this issue each year. Once referred to a gynaecologist, 60 per cent of women suffering from menorrhagia will have their womb removed (hysterectomy) within five years, accounting for up to 75 per cent of all hysterectomies performed worldwide.
A 2006 survey with 2,411 secondary school girls in Malaysia reported that about 18 per cent suffered excessive menstrual loss and 0.4 per cent of them were confirmed to be anaemic.
The medical definition of heavy menstrual bleeding is the loss of more than 80ml of blood each period. As it is seldom realistic or practical for a woman to actually measure her blood loss, doctors would rely on the woman's description of her period.
Periods are considered heavy when a woman:
Bleeds for more than eight to 10 days, especially if this is repeated month after month. Bleeds so much that it is difficult for her to attend to her job, or she has to put her normal life on hold just to deal with the heavy blood flow. Becomes anaemic because the bleeding is continuously very heavy. Finds other than small clots for more than one or two days. Experiences "flooding" - the sudden, unexpected onset of periods, like turning on a tap. Needs to change her tampon or a pad every hour.
Common causes of heavy menstrual bleeding
These include the following:
● Hormonal imbalances - In a normal menstrual cycle, a balance between the reproductive hormones oestrogen and progesterone regulates the buildup of the inner lining of the womb, which is shed during menstruation.
If hormonal imbalance occurs, the inner lining of the womb develops in excess and eventually sheds by way of heavy menstrual bleeding.
In younger women, or those approaching menopause, heavy periods are most often due to a temporary hormonal imbalance, which eventually corrects itself. However, as a woman ages, heavy periods may also be caused by an underlying disease.
If you are past menopause and experience any vaginal bleeding, discuss your symptoms with your doctor right away.
● Certain gynaecological conditions such as uterine fibroids, polyps (which are benign growths on the lining of the uterine wall), as well as uterine, ovarian and cervical cancers. Heavy bleeding can also be due to complications of pregnancy like miscarriages and ectopic pregnancy (when a fertilised egg is implanted and grows outside the uterus).
● Use of the non-hormonal intrauterine device (copper) for birth control.
● Certain drugs, including anti-inflammatory medications and anticoagulants, as well as improper use of hormone medications.
● Other medical conditions like pelvic inflammatory disease, thyroid problems, endometriosis, and liver or kidney disease.
What will the doctor do?
Initial blood tests are done to assess if excessive blood loss during menstruation has made you anaemic, and to check for any other underlying causes. Your doctor may also conduct a Pap smear to check for changes in the cells of your cervix (lower part of the womb), which may indicate infection, inflammation or cancer.
An ultrasound scan or hysteroscopy are more specialised investigations which enable visualisation of the inside of your womb.
The right treatment for you will depend on the cause of your heavy periods. It will also depend on other factors, such as your overall health, the severity of your condition, and its impact on your life.
In cases where your heavy periods are the result of fibroids or cancer, treatment will be aimed at managing those conditions first.
If your heavy periods are due to a hormonal imbalance and there are no signs of an underlying abnormality, treatment is not absolutely necessary, but most women prefer to have something to help them cope more easily each month.
If you are anaemic, iron or folic acid supplements may be needed. If your condition is severe, bleeding may be regulated by hormonal or non-hormonal therapy.
Hormone therapy with combined oral contraceptives (birth control pills) or progesterone only pills can help regulate ovulation and effectively reduce heavy menstrual bleeding. Discontinuation of hormone therapy will have no effect on fertility.
Recently, an oral hormonal treatment option for heavy menstrual bleeding, with contraceptive benefits, was approved in Malaysia. Containing oestradiol valerate, and a new progestin called dienogest, this treatment option mimics the natural balance of hormones in a woman's body.
Alternative approaches include the hormonal levonorgestrel intrauterine system, which is particularly beneficial for women with heavy menstrual bleeding who require contraception.
Non-hormonal treatments include non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen (help relief painful menstrual cramps), and tranexamic acid (prevents the breakdown of fibrin in blood clots).
If drug therapy is unsuccessful, you may need surgical intervention, such as a D&C, which is scraping the inner lining of the womb.
For women who do not wish to have more children, destroying the lining of the womb by laser or heat, or a hysterectomy (the removal of the uterus), may be performed. However, some procedures may need to be repeated to avoid problems recurring.
It is essential that we identify our problems and seek solutions so that we can live life to its fullest. So if you dread "that time of the month" because you have to put your life on hold, it's about time you pay a visit to your doctor.
This article is contributed by Dr Kalpana Nayar, medical advisor with Bayer HealthCare.