Heavy Menstrual Bleeding: Causes, Diagnosis, and Treatment

The average period comes every 28-30 days, lasts 3-6 days, and typically has 1-2 heavier flow days then tapers off.  Every woman is different and blood flow pattern can change over time. Typically, earlier on in the adolescent and teenage years, periods can be heavier and last longer.  Over time, this should lessen. But in many women, heavy menstrual bleeding continues throughout the reproductive years. While this is a common experience, heavy menstrual bleeding warrants a visit to your doctor, preferably a gynecologist.

What is Heavy Menstrual Bleeding?

The medical term for heavy menstrual bleeding is “menorrhagia”.  Typically, it is recognized by taking note of how often you change a pad or tampon.  If your flow causes you to need to change pads/tampons more than every 1-2 hours, you are soaking through your clothes, you require more than one pad at a time, or you bleed through even an extra long or super absorbency product overnight, you are experiencing heavy menstrual bleeding.  Also, if your periods last more than 7 days, you have heavy menstrual bleeding.

What Causes Heavy Menstrual Bleeding?

The list of potential causes of heavy menstrual bleeding is long.  Most are benign (non-cancerous) reasons such as ovulatory dysfunction from hormonal abnormalities, uterine fibroids or polyps, adenomyosis, infection, or bleeding disorders.

Ovulatory Dysfunction

Ovulatory dysfunction occurs when a woman does not ovulate (release an egg) regularly each month.  This leads to thickening of the lining of the uterus and heavy periods when bleeding does occur. Ovulatory dysfunction is most common during adolescence when periods first start or perimenopause when periods are stopping.  It can also occur with certain medical conditions such as hypothyroidism and polycystic ovarian syndrome (PCOS).

Uterine Fibroids

Fibroids are benign growths which develop within the muscle, inside, or on the surface the uterus.  They are most common in African American and Latino women. The exact cause of fibroids is unknown. They can range in number and size and affect different women differently.  For example, small fibroids (less than 3 centimeters) are typically asymptomatic and many women do not even know they have them. Contrastingly, in some women, fibroids grow very large (10 centimeters or greater) or many are present, and they cause symptoms such as heavy periods, bloating, painful sex, infertility, and even bladder/bowel problems.  While fibroids are not dangerous, they can be quite bothersome. They grow in the presence of estrogen and thus can increase in size during the reproductive years and pregnancy and typically shrink after menopause. They are typically diagnosed by ultrasound.

Uterine Polyps

Polyps are benign growths which develop on the inside lining of the uterus.  They are typically benign (non-cancerous) and can occur in women of all ages.  The cause of uterine polyps is uncertain.

Adenomyosis

Adenomyosis is a condition where there are normal cells in an abnormal place.  Different from endometriosis which is where the uterine lining grows in placed outside of the uterus such as on the ovaries, in the pelvis, or even on intestines, in adenomyosis, the inner lining of the uterus grows into the muscular layers of the uterus.  The uterus becomes enlarged and “spongy”, causing pain and heavy bleeding.

Infection

The two most common uterine infections are pelvic inflammatory disease (PID) and endometritis.  In PID, one or more of the reproductive organs (such as the uterus, fallopian tubes, or cervix) become infected typically by an untreated sexually transmitted infection such as gonorrhea or chlamydia.  In endometritis, the uterine lining becomes infected or inflamed following childbirth, abortion, or other gynecological procedures. In both of these conditions, the uterus is very tender and prolonged bleeding or spotting is common.    

Bleeding Disorders

There are several types of bleeding disorders, however the most common type in women is von Willebrand disease.  This is a genetic condition caused by a missing or defective protein in the which helps blood clot. This leads to increased and prolonged bleeding.  Other bleeding problems can be caused by having a low platelet count or being on a blood thinning medication.

Other Causes

Other potential causes of heavy menstrual bleeding in exist, so it is important to see your doctor for a proper diagnosis and evaluation.

How is the Cause of Heavy Menstrual Bleeding Diagnosed?

The first thing your gynecologist will do when evaluating your heavy menstrual bleeding is ask you about the frequency, amount, and duration of your periods so it is helpful to keep notes about your period for the past few months.  For example, how many days did you bleed? How many pads or tampons did you use on your heaviest day of flow? It is also important to make a list of all of your medications (including over the counter and vitamin supplements) to bring to your appointment.

A pelvic examination is typically performed to feel for the size and shape of your uterus and ovaries.  Based on your symptoms and the findings of your examination, your physician may order:

Sometimes, your physician may perform a procedure in the office called a “hysteroscopy” to look inside of your uterus with a camera or take a sample of the lining of your uterus with a very small suction tube.  

How is Heavy Menstrual Bleeding Treated?

Treatment of heavy menstrual bleeding depends on the cause.  

In cases of ovulatory dysfunction, if irregular ovulation is the cause, birth control methods or hormone therapy can usually regulate the cycles.  If thyroid levels are abnormal, treating imbalances can restore normal ovulation and bleeding patterns.

Uterine fibroids have many different forms of treatment.  Birth control methods can help reduce the amount of bleeding which occurs each menstrual period.  Progesterone-releasing intrauterine devices (IUDs) can also be beneficial in many patients. In cases where the fibroids are large, another medication called a gonadotropin-releasing hormone (GnRH) agonist is sometimes used to shrink the size of the fibroids, however if can only be used for a short period of time.  This medication is typically reserved for patients who are going to have surgery for their fibroids but the physician wants to decrease the size to made the surgery less difficult and prevent excessive blood loss. Several surgical treatments are available to treat fibroids. A myomectomy (opening the abdomen with a c-section type of incision and removing the fibroids but leaving the uterus in place) is typically performed for large, symptomatic fibroids in women who want to maintain fertility;  however fibroids may grow back over time. For patients who have completed childbearing, a hysterectomy (removing the uterus through an incision in the abdomen, laparoscopically, or vaginally) is curative. For smaller fibroids which are entering the cavity of the uterus, a Myosure procedure (placing a camera device through the vagina, into the uterus, and shaving the fibroid off) can be done in the office under local anesthesia. For patients who have medical problems which may affect their ability to safely be put to sleep for surgery, a uterine artery embolization (cutting off the blood supply to the fibroids through a coil placed into the groin) may be a suitable option.  

Treatment for uterine polyps typically involves removal.  This can be done in the office with a small camera inserted through the vaginal into the uterus.  The polyp is identified then gently grasped and removed. There is minimal discomfort with this procedure as it is done under local anesthesia.  

While abnormal bleeding can be reduced with hormonal birth control methods, the definitive treatment for adenomyosis is a hysterectomy.  This is typically performed once childbearing is completed.

Both pelvic inflammatory disease and endometritis are treated with antibiotics.  In the case of endometritis, an anti-inflammatory just as ibuprofen may also be helpful.

Treatments for bleeding disorders may involve taking steroids to prevent the breakdown of platelets, administering intravenous (through the vein) immunotherapy to prevent self-destruction of platelets, or replacing clotting factors into the blood or with nasal sprays.  

In addition to the treatments listed above for specific conditions, all causes of heavy menstrual bleeding can sometimes be treated with a medication called Lysteda which prevents the breakdown of blood clots, allowing them to function and stop bleeding.  This medication is typically taking while on your period.

When is Menstrual Bleeding a Medical Emergency?

If you are having severe bleeding, soaking more than 2 pads per hour for 2 hours, or you have feelings of lightheadedness, dizziness, or pass out, you should proceed to the emergency room immediately. 

A Final Message

Understanding the reason for your heavy menstrual bleeding is important not only for your quality of life but for your overall health.  Heavy or prolonged blood loss can cause anemia which can lead to symptoms of fatigue, shortness of breath, and dizziness. Once the bleeding cause is identified and the treatment is started, you can feel better and be healthier overall!


Author
Ameigh Worley MD, FACOG "Dedicated to women and the gift of life."

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