Menorrhagia

INTRODUCTION

Menorrhagia is excessive menstrual flow lasting more than 7 days or in a woman who uses extra sanitary pads. An average sanitary pad holds 5 – 15 ml of blood. If a lady uses more than 10 – 15 pads, and they are heavily soaked it could be a pointer to menorrhagia. In many cases, blood clots are produced during menstrual flow. Menstruation in these cases occurs at regular intervals.

As many as 10 out of 100 gynecologic clinic consultations is for menorrhagia. The symptoms are more common in women above 30 years. Menorrhagia most times is the result of an underlying pathology either in the uterus or other parts of the body.

 

SYMPTOMS

A lady with menorrhagia will present with:

• Heavy flow lasting more than 7 days
• Other symptoms could be a reflection of the disease-causing the menorrhagia

 

CAUSES

Every month, after a lady’s menses the follicles begin to grow [under the influence of FSH from the pituitary gland] and produce estrogen. Estrogen acts on the lining of the uterus to become proliferative and grow. After ovulation, the corpus luteum secretes progesterone which converts the proliferative endometrium to secretory. If no pregnancy occurs this secretory endometrium sloughs off as menstrual blood in a predictable pattern. This bleeding usually lasts 2 – 7 days with a cycle interval of 21 – 35 days for the majority of women.

Several conditions can cause menstrual bleeding to get prolonged or heavier than normal. They include:

Organic causes

An organic disease is one caused by a physical or physiological change to some tissue or organ of the body. These include conditions such as:

• Disorders of blood clotting [blood clots take a longer time to form and stop the bleeding]
• Liver diseases reduce the production of clotting factors and cause estrogen to keep acting for a longer time.

Endocrine causes

Endocrine disorders result when a gland produces too much or too little of an endocrine hormone leading to a hormonal imbalance. These include conditions such as:

• Thyroid disorders such as elevated or low thyroid hormone levels
• Prolactin secreting tumour producing excessive prolactin which inhibits ovulation.
• Polycystic ovarian syndrome leading to excess androgen [gets converted to estrogen causing longer bleeding episodes].

Iatrogenic causes

These are due to the activity of a physician or a treatment. Causes include:

• Intrauterine contraceptive devices [IUCD] for family planning

Anatomic causes

Anatomic disorders result in problems within the uterus. These include conditions such as:

• Uterine fibroid,
• Endometrial polyp,
• Endometrial hyperplasia

 

PREVENTION

If the cause of the menorrhagia is found it could be avoided, if possible.

 

COMPLICATIONS

It is important to make an early diagnosis of menorrhagia so the client can be evaluated properly to rule out more serious causes of the bleeding. Complications that could arise from the disorder include:

Anaemia

Frequent heavy bleeding could lead to anaemia, which may necessitate blood transfusions.

Increased risk related to other conditions

Conditions such as liver disease, thyroid disorders, etc. could progress if not detected on time.

 

DIAGNOSIS

Diagnosing menorrhagia usually begins with a history of the above symptoms: heavy menses lasting more than 7 days with associated blood clots. A clinical and pelvic examination will be carried out which could pick up telltale signs of the disease.

Laboratory test done may include:

• Full blood count. Detects anaemia and the presence of low platelet count
• Hormonal assay to assess the level of serum Follicle Stimulating Hormone [FSH], Luteinizing hormone [LH] and Estradiol on day 3 of menses. Prolactin and testosterone levels may also be indicated.
• Liver function test. To check if the liver functions are deranged from disease.
• Pregnancy test. Done to exclude a pregnancy.

An ultrasound scan of the uterus will detect fibroids, polyps, endometrial hyperplasia.

A hysteroscopy will usually be indicated to evaluate the endometrial lining for anatomic defects.

An MRI of the hypothalamus and pituitary may be useful in where a tumour of the pituitary gland is suspected.

 

TREATMENT

Medical treatment

Treatment is usually targeted at reducing the bleeding and tackling the coexisting disease which may be responsible for the bleeding such as treatment for liver disease, thyroid disorders, etc.

Treatment for reducing bleeding includes:

• Oral contraceptive pills
• Non-steroidal anti-inflammatory drugs [NSAIDs]. Drugs such as cataflam, Ibuprofen.
• Progestin only such as provera, mirena.
• Gonadotrophin releasing hormone agonists [GnRH] such as Zoladex, Lupron.

Surgical treatment

This offers a lasting solution for conditions of the uterus such as fibroids, endometrial hyperplasia, polyps, etc.

Options include:

• Endometrial ablation
• Myomectomy
• Hysteroscopic polypectomy
• Hysteroscopic myomectomy
• Laparoscopic hysterectomy
• Uterine artery embolization

 

WHEN TO SEE A DOCTOR

You are advised to see your doctor if you experience the following.

1. If you have heavy menses
2. If you have features of anaemia [weakness, fainting attacks]