Imagine losing so much blood - through menstruation - that you need a blood transfusion. That happened to nine women earlier this year, all of whom were admitted to the National University Hospital (NUH) for severe bleeding over a five-month period.
It is not terribly common, but worrying enough as doctors believe it could be the tip of the iceberg where heavy menses is concerned.
In a quick audit carried out by NUH, of the 30 women who were admitted for heavy menstrual bleeding, nine needed blood transfusions and 20 had anaemia, of which 12 were severe anaemia, reports Fong Yoke Fai, Head & Senior Consultant, Division of Benign Gynaecology, Department of Obstetrics & Gynaecology, National University Hospital.
The average age of the women was 38.3 years, but they ranged from as young as 21 to 51 years old - an indication that the condition affects women of all ages within the reproductive group, points out Dr Fong. "Some have had it for three months, and some for three years. For most, it has been a long-standing event."
The hospital admission data could well represent the tip of the iceberg, believes Dr Fong, who is also the President of the Obstetrical & Gynaecological Society of Singapore.
Heavy menstrual bleeding isn't a new phenomena but affects some 5-10 per cent of women and this percentage has stayed roughly the same. There is a natural reluctance among women to come forward to seek treatment until their condition is severe enough to warrant hospital admission, Dr Fong notes.
"There could be a lack of awareness among them, but also, if the women find ways to cope with the heavy flow, they will delay seeking treatment," he says, adding that a lot of women will simply adjust their lifestyle to accommodate the heavy bleeding even though it is abnormal. "They may not go out or restrict their activities; and some will accommodate their problem by placing a plastic sheet over their bed, for example.
"Many of these women suffer in silence because they do not know the difference between a normal period and excessive menstrual blood loss, or they do not realise it can be treated," he says. Especially when heavy menstrual bleeding isn't necessarily accompanied with pain.
But anaemia is a severe consequence of heavy menstrual bleeding, and signs for anaemia include heart palpitations, a fast heart beat, shortness of breath and, on exertion, tiredness and feeling drained out.
When the haemoglobins are less than half of the normal levels, anaemia can lead to heart failure. Another consequence of anaemia is that sufferers are more prone to infection and delayed healing in tissues.
Dr Fong says that it is important to determine the cause of the heavy bleeding, which can be due to several factors, such as hormonal imbalance, fibroids, endometriosis and adenomyosis (endometriosis of the womb instead of the ovaries).
"Fibroids might cause heavy bleeding but they won't be painful while adenomyosis might be," he explains.
Early diagnosis and treatment might alleviate the problem. In extreme cases, the womb might have to be surgically removed, especially in adenomyosis cases.
Traditional treatment options, says Dr Fong, have included surgery (but only as the last resort), non-hormonal medication and, most recently, the first and only oral treatment for heavy menstrual bleeding, with contraceptive benefit. The new medicine, Qlaira, is taken specifically for bleeding and reduces menstrual flow, and can be taken whether or not there is pain. "The reduction in menstrual flow is rapid and sustainable, and there are also fewer side effects," Dr Fong explains.
He advises: "The first thing is to get a proper diagnosis of the case, and then treatment can be given accordingly. If the condition is caught early enough, patients normally respond well."