Menstrual Disorders

Menstruation disorders are a common problem during adolescence. These disorders may cause significant anxiety for patients and their families. Physical and psychological factors contribute to the problem. In order to treat menstruation disorders, becoming familiar with the normal menstrual cycle is important.

The median age of menarche (the first menstrual period) is 12.77 years. Most cycles occur between 21-35 days with 3-7 days of bleeding and 30-40 mL of blood loss. Anovulatory cycles and irregular menstrual patterns are common within 24 months of menarche. A heavy period is a blood loss of 60-80 ml or more.

Definition

Menorrhagia is the medical term for menstrual periods in which bleeding is abnormally heavy or prolonged. Although heavy menstrual bleeding is a common concern among premenopausal women, most women don't experience blood loss severe enough to be defined as menorrhagia.

With menorrhagia, every period you have causes enough blood loss and cramping that you can't maintain your usual activities. If you have menstrual bleeding so heavy that you dread your period, you need to see your doctor. There are many effective treatments for menorrhagia.

Symptoms

The signs and symptoms of menorrhagia may include:

Soaking through one or more sanitary pads or tampons every hour for several consecutive hours

Needing to use double sanitary protection to control your menstrual flow

Bleeding for a week or longer

Passing large blood clots with menstrual flow

Restricting daily activitiesdue to heavy menstrual flow

Symptoms of anemia, such as tiredness, fatigue or shortness of breath

Causes

In some cases, the cause of heavy menstrual bleeding is unknown, but a number of conditions may cause menorrhagia. Common causes include:

Hormonal imbalance. In a normal menstrual cycle, a balance between the hormones estrogen and progesterone regulates the buildup of the lining of the uterus (endometrium), which is shed during menstruation. If a hormonal imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding.

Dysfunction of the ovaries. If ovulation does not occur in a menstrual cycle (anovulation), progesterone is not produced. This causes hormonal imbalance and may result in menorrhagia.

Uterine fibroids.These noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.

Polyps.Small, benign growths on the lining of the uterine wall (uterine polyps) may cause heavy or prolonged menstrual bleeding. Polyps of the uterus most commonly occur in women of reproductive age as the result of high hormone levels.

Adenomyosis. This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and painful menses. Adenomyosis is most likely to develop if you're a middle-aged woman who has had children.

Intrauterine device (IUD). Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for birth control. When an IUD is the cause of excessive menstrual bleeding, you may need to remove it.

Pregnancy complications. A single, heavy, late period may be due to a miscarriage. If bleeding occurs at the usual time of menstruation, however, miscarriage is unlikely to be the cause.

Cancer. Rarely, uterine cancer, ovarian cancer and cervical cancer can cause excessive menstrual bleeding.

Inherited bleeding disorders. Some blood coagulation disorders — such as von Willebrand's disease, a condition in which an important blood-clotting factor is deficient or impaired — can cause abnormal menstrual bleeding.

Medications. Anticoagulants, can contribute to heavy or prolonged menstrual bleeding. Improper use of hormone medications also can cause menorrhagia.

Other medical conditions. A number of other medical conditions, including pelvic inflammatory disease (PID), thyroid problems, endometriosis, and liver or kidney disease, may be associated with menorrhagia.

Risk factors

Menorrhagia is most often due to a hormonal imbalance that causes menstrual cycles without ovulation. In a normal cycle, the release of an egg from the ovaries stimulates the body's production of progesterone, the female hormone most responsible for keeping periods regular. When no egg is released, insufficient progesterone can cause heavy menstrual bleeding. Menstrual cycles without ovulation (anovulatory cycles) are most common among two separate age groups:

Adolescent girls who have recently started menstruating. Girls are especially prone to anovulatory cycles in the first year to two years after their first menstrual period.

Older women approaching menopause. Women ages 40 to 50 are at increased risk of hormonal changes that lead to anovulatory cycles.

What are the treatment options for heavy periods?

Treatment aims to reduce the amount of blood loss.

Levonorgestrel intrauterine system (Mirena)

Mirena is an intrauterine contraceptive device (IUCD, or coil). It is inserted into the uterus and slowly releases a small amount of a progestogen hormone called levonorgestrel. The amount of hormone released each day is tiny but sufficient to work inside the uterus. In most women, bleeding becomes either very light or stops altogether within 3-6 months of starting this treatment. Period pain is usually reduced too. However, the light periods may become irregular. Mirena works mainly by making the lining of the uterus very thin.Each device lasts five years, although it can be taken out at any time. It is particularly useful for women who require long-term contraception, as it is also a reliable form of contraception. This is, however, not usually suitable if you do not need long-term contraception.

Tranexamic acid tablets

Treatment with tranexamic acid can reduce the heaviness of bleeding by almost half (40-50%) in most cases. Tranexamic acid works by reducing the breakdown of blood clots in the uterus. In effect, it strengthens the blood clots in the uterus lining which leads to less bleeding.

Anti-inflammatory painkillers

These medicines reduce the blood loss by about a third (20-50%) in most cases. They also ease period pain. You need to take the tablets for a few days during each period. They work by reducing the high level of prostaglandin in the uterus lining which seems to contribute to heavy periods and period pain. However, they do not reduce the number of days the period lasts.

The combined oral contraceptive pill (COCP)

This reduces bleeding by at least a third in most women. It often helps with period pain too. It is a popular treatment with women who also want contraception, but who do not want to use the Mirena. If required, you can take this in addition to anti-inflammatory painkillers, particularly if period pain is a problem.

Norethisterone

Norethisterone is a progestogen medicine. It is not commonly used to treat heavy periods. It is sometimes considered if other treatments have not worked, are unsuitable or are not wanted.
The reason why norethisterone is not commonly used as a regular treatment is because many women get side-effects, such as bloating, fluid retention, breast tenderness, nausea, headache and dizziness. However, norethisterone is used as a temporary measure to stop very heavy menstrual bleeding.

Surgical treatment

Having surgery is not a first-line treatment. It is an option if the above treatments do not help or are unsuitable:

Removing or destroying the lining of the uterus - endometrial ablation. This treatment is suitable only for women whose family is complete.

Hysterectomy is the operation where the uterus is totally removed. However, hysterectomy is done much less commonly these days since endometrial ablation became available. It may be considered if all other treatment options have not worked for you.

 
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