Abnormally heavy flow

Menstruation or periods are a woman's normal monthly physiological bleeding. However, what most women do not realise is that heavy menstrual bleeding is not normal.

I, too, was not aware of this since my own cycle had never interfered with my daily routine.

"Many women suffer in silence because they don't know the difference between a normal period and excessive menstrual blood loss. Nor do they realise it can be treated," says obstetrician, gynaecologist and gynaecological oncologist Dr Suresh Kumarasamy.

A normal menstrual cycle is characterised by blood loss of about 40ml and lasts an average period of four days.

Heavy flow

According to Britain's National Institute for Health and Clinical Excellence Guideline 44 (2007), heavy menstrual bleeding (HMB) is defined as "excessive menstrual blood loss which interferes with a woman's physical, emotional, social and material quality of life and which can occur alone or in combination with other symptoms".

The most common causes of abnormal uterine bleeding are hormonal imbalances and gynaecological conditions as well as pregnancy complications.

"A woman having ovulatory disorders will not produce egg during ovulation but will continue to produce oestrogen. This causes the lining to thicken and eventually outgrow the blood supply," explains Dr Kumarasamy.

The imbalance in the control mechanism results in prolonged bleeding as there is not enough progesterone to stop it.

Hereditary factor

There is no evidence linking HMB to lifestyle or eating habits. It can, however, be hereditary.

In a 12-month local study of 500 women aged 18-49 years old, 22 per cent experienced HMB and 74 per cent of these were either married or living with a partner.

However only two in five women who experienced HMB, had been diagnosed by a doctor.

"Some women ignore it as they are afraid it may be more than just heavy bleeding. Either way, they need to be treated," says consultant obstetrician and gynaecologist Dr Premitha Damodaran.

The condition is most prevalent among women in their 30s.

Monthly distress

Monthly distress

On the other hand, out of 100 women with HMB, 33 per cent are aware but are not bothered by it while 34 per cent say HMB interferes with their daily activities.

Some women suffering from HMB even skip social events and do not sit still for long periods of time.

"Some women say they're not bothered by it but in reality, they are used to planning events around their menstrual cycle," says Dr Premitha. "Women who suffer heavy menstrual bleeding often experience physical fatigue, emotional distress and are anaemic. This is not beneficial to their health in the long term, and they should seek treatment."

Women should realise that treating HMB is not just about reducing blood loss but also about improving the quality of life.

Some side effects of HMB are lethargy, lack of strength, pelvic pain and disrupted sleep. In isolation, these may seem minor but combined, they do have an impact on work performance, relationships and sexual life.

Keeping tabs

To identify HMB, women should keep a diary of bleeding and non-bleeding days including notes on how heavy the flow is. This will increase the accuracy of patient's medical history and help with doctor's diagnosis.

Following a physical exam, a patient may be required to undergo an ultrasound scan, blood test, pap smear or endometrial biopsy.

Treatment depends on the cause, overall health, severity of the condition and the impact on the patient's life. There are two types of drug therapy for HMB - hormone and non-hormonal therapy.

If drug therapy is unsuccessful, surgical intervention such as dilation and curettage (D&C) and hysterectomy may be necessary. However, there are limitations to current treatment options.

"Surgical treatments are invasive, come with certain risks, may need to be repeated and may not be suitable for all women, especially those who still want to preserve their fertility," says Dr Kumarasamy.

New method

A new oral therapy approved in the country for the treatment of heavy menstrual bleeding, with an added contraceptive benefit, combines estradiol (similar to the oestrogen produced naturally in a woman's body) and dienogest (a progestin with a focused endometrial effect).

"Clinical evidence confirms that estradiol valerate/dienogest is an attractive treatment option for women with heavy and frequent menstrual bleeding. Not only does it offer women rapid, significant and sustained reduction in menstrual blood loss but it also has a good bleeding profile." says Dr Ian Milsom, professor of obstetrics and gynaecology at Sahlgrenska University Hospital, Sweden.

Heavy menstrual bleeding is a key cause of ill health in women, affecting an estimated nine to 30 per cent of women of reproductive age. "This offers women an effective and convenient oral treatment option that is in harmony with their bodies, a better quality of life and improved overall health, particularly for women who are anaemic due to heavy menstrual bleeding," he adds.

Signs and symptoms

  • Soaking through one or more tampons or pads in one hour
  • Needs double sanitary protection
  • Needs to change sanitary protection during the night
  • Periods that last more than seven days
  • Large blood clots in menstrual blood
  • Symptoms of anaemia - tiredness, fatigue, shortness of breath
  • Painful periods