What are heavy periods?
A heavy period (also known as menorrhagia or heavy menstrual bleeding) is the excessive menstrual loss that happens regularly and affects your physical, emotional, social and professional quality of life. Another definition of period being heavy is when you have to change a pad every one to two hours.
The frequency of heavy periods increases with age, peaking in women between 30-49 years. Up to a quarter of all women will have at least one heavy period during their reproductive age. In the UK one in five women has a hysterectomy before the age of 60 to treat heavy periods.
What causes heavy periods?
Despite all of our technology and available investigations, we cannot identify a cause in 50% of women with heavy periods; this is known as dysfunctional uterine bleeding. In the other half of the women with heavy periods however, the most common reasons that can be identified are:
Fibroids: Up to 40% of women with heavy periods have fibroids.
Endometriosis: Endometriosis usually causes pain but heavy periods are very common as well.
Adenomyosis: Is the condition where the lining of the womb grows within the muscle of the womb. This causes heavy and painful periods, pelvic pain and pain during intercourse.
Precancerous or cancerous changes of the lining of the womb
Bleeding disorders: These rare conditions are associated with excessive bleeding. Family or personal history usually triggers the relevant investigations.
Under-active thyroid (hypothyroidism): This may also presents with fatigue, constipation, intolerance of cold and hair or skin changes.
How do we investigate them?
If your periods are heavy, we aim to identify the cause as well as assessing the impact of the periods on your wellbeing. The most common tests are:
Pelvic examination: An examination of your pelvis and abdomen will give the first indication of a big womb, raising the suspicion of fibroids or adenomyosis. We will also check your cervix and take a smear if one is due.
Full blood count: It will show us whether your haemoglobin (related to iron levels) is low, in other words whether you have anaemia. This is a strong indicator of excessive menstrual bleeding.
Thyroid function tests: Especially if you have symptoms of thyroid disease.
Tests for coagulation disorders: These tests should be considered in women with heavy periods since their beginning or a family history of bleeding tendencies.
Transvaginal/transabdominal ultrasound scan: If the womb feels big on palpation, or if there is the suspicion of a pelvic mass, an internal (vaginal) scan will give us accurate pictures of your womb and ovaries. This will help us to formulate an individualised management plan for you.
Hysteroscopy & endometrial biopsy: During the hysteroscopy a small scope is inserted into your womb to allow us to directly visualise its lining. This way we can accurately assess the size and appearance of fibroids or polyps you may possibly have, especially if the ultrasound scan is inconclusive. This will also help us to exclude cancer of the lining of the womb. A hysteroscopy is indicated in cases where the bleeding persists despite treatment.
What is the treatment for heavy periods?
Treating heavy periods can prove very challenging. It depends on your fertility wishes, contraindications for medications, risk factors for surgery and the severity of your symptoms. It is usually a step-based approach.
Medical Treatment. Is an option for most women especially if it has not been tried before. Which option you will choose depends entirely on you.
The Mirena coil: It contains 52mg of levonorgestrel (a type of progesterone) and is licensed for up to 5 years use. It releases small amounts of the hormone daily and has 60-70% chance of improving if not stopping your periods all together.
Tranexamic acid: Improves the heavy bleeding by about 30% by helping the blood to clot.
Mefenamic acid: Is a similar type of drug to ibuprofen or diclofenac (non-steroidal anti-inflammatory drug, NSAID) and improves pain and heavy bleeding.
Norethisterone: It is another form of progesterone and is given as a tablet. It reduces the thickness of the lining of the womb and makes the periods lighter.
Endometrial ablation: It involves the cauterisation of the lining of the womb either with diathermy or balloon techniques. It is a day case and has a 60-70% chance of improving your heavy periods.
Myomectomy: When a fibroid is responsible for the heavy periods, removing it (with an operation called myomectomy) usually makes the bleeding lighter. It may also improve your chances of getting pregnant.
Hysterectomy: The last resort. It includes the removal of the womb, the fallopian tubes with or without the ovaries. It relieves symptoms, provides permanent contraception and stops the heavy periods once and for all.