Menorrhagia: Heavy Flow Explained

Menorrhagia is a condition in which a woman has a heavy flow of menses than normal but with regular monthly cycle rhythm. This can come as either bleeding heavily for a few days as usual or she may bleed for more than 7 days. It is a diagnosis made in women that are still in reproductive age and is one of the concerning gynecologic symptoms.

There are many causes of heavy menstrual flow, most of them can be treated easily without the need for surgery while some may need surgical intervention. Careful history and physical examination in is all that’s required to diagnose menorrhagia, then a cause can be found by doing relevant tests which are sometimes not necessary.

If left untreated or not evaluated properly, menorrhagia can lead to complications such as anaemia or a person may be having a serious underlying medical condition.

Menorrhagia should be differentiated from the following medical terms which are closely related:

  • Amenorrhea: This refers to absence of menses for extended period of time or a delay in starting periods. Read Here for details.
  • Metrorrhagia: It is Irregular menstrual cycle with person skipping months
  • Polymenorrhea: It is having periods very frequently with cycle lasting less than 21 days

Causes of Menorrhagia

Pregnancy in a woman of reproductive age should always be suspected and be ruled out if she presents with menstrual issues, even if she is using contraceptives since they sometimes fail. Causes can either be systemic or be localized in the pelvic region.

1.      Bleeding disorders

Under normal circumstances, bleeding that occurs during menstrual flow is supposed to be between 20-80ml blood loss and the body is expected stop the bleeding within 5-7 days. People with bleeding disorders such as:

  1. Haemophilia
  2. Low platelet count and medical conditions that cause low platelets e.g. ITP and bone marrow disorders
  3. People on anticoagulants like warfarin, Heparin and aspirin

2.      Thyroid disorders

There are two main types of thyroid disorders that are common, Hyperthyroidism and Hypothyroidism.

Both conditions can cause heavy menses although it is more common in Hyperthyroidism. Thyroid disorders can be detected by doing blood tests called Thyroid Function Tests.

3.      Hormonal imbalance

If a woman is using hormonal contraceptives as a prevention method, which come as oral pills or injectable hormones, she may have imbalance in the hormones leading to heavy flow.

This happens in the first few months of starting to take the pill or after an injection with hormonal contraceptives, then again a few months after stopping use of contraceptives. Reason being the fact that the body is adjusting to the introduction of new hormones in its blood or withdrawal of such hormone.

As a result, sometimes hormonal contraceptives are used to treat Amenorrhea.

Psychological stress also cause hormones to have imbalance and is a risk factor of Menorrhagia.

4.      Other causes and Risk factors

Uterus with fibroids

There are many more uncategorized causes and risk factors of heavy flow which medical practitioners have to investigate and treat if detected. These include:

  • Polycystic ovarian Syndrome (PCOS)
  • Fibroids
  • Obesity
  • Smoking and alcohol abuse
  • Liver disease
  • Hyperprolactinemia
  • Cervicitis
  • Cancer

Approach to Diagnosis

History and physical examination give clear clues about the possible cause of Menorrhagia. For example if the person has heavy flow following injection with contraceptives, it is clear that there is hormonal imbalance in that case.

Pregnancy test in the urine is the NUMBER ONE TEST!

 Blood tests: They include Complete Blood Count (Full Blood Count), Thyroid function tests like TSH,T3 and T4. Blood clotting profile and prolactin levels. Other additional blood tests are done if physical exam findings suggests that a certain organ is affected e.g. Liver Function Tests are done if there are other signs of liver disease.

Ultrasound scan: It is done if the bleeding is persistent even after the initial treatment. It may reveal pelvic abnormalities that require specialist involvement. All women more than 45 years with abnormal bleeding should be done ultrasound.

When Should You Worry? Red flags

You should sick medical care if you have one or more of the following:

  1. Bleeding for more than 7 days
  2. Nipple discharge
  3. Severe lower abdominal pain
  4. Dizziness, headache, palpitations and excessive fatigue as you might be having anemia.
  5. Easy bruising and Nosebleed.

Treatment of Menorrhagia

There are two steps involved in treating heavy flow:

Step 1: Stop the bleeding

Bleeding is stopped using one of the following methods:

  • Tranexamic Acid (Cyclokapron® ) 1g oral 6 hourly for 4 days OR
  • Norethisterone (Norethindrone) 5mg oral every 4 hours until bleeding stops up to maximum 48 hours.

Step 2: Find the cause

Basic investigations such as laboratory blood tests listed above are done if the cause is not known. When found then it is treated and the symptoms resolve.

In most cases the bleeding stops before the cause is found and normal cycle returns.

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