Menorrhagia is defined as the occurrence of excessive bleeding (with respect to quantity or duration) during periods, with the periods themselves being regular. This is clinically defined as more than 80 mL blood loss during each period, or periods lasting more than 7 days. A normal period comes every 21-35 days, with an average of 25-80 mL of blood being lost during each cycle.

Risk factors

The most common factors that are associated with menorrhagia include:

• Pregnancy (to be ruled out in all women who are sexually active and of reproductive age)
• Pelvic pain
• Pelvic disease such as fibroids or adenomyosis
• endometriosis
• Sexually transmitted infections
• Pelvic inflammatory disease
• Anovulatory conditions especially PCOS (polycystic ovarian syndrome)
• Hormonal disturbances which prevent normal ovarian function
• Bleeding disorders like platelet deficiency
• Chronic illness of the kidney or diabetes
• Treatment with hormones or anticoagulants

Signs of underlying disease

A physical examination may throw up signs of conditions which cause or contribute to the menorrhagia. They will also show if there is obvious anemia as a result of severe blood loss, or if the bleeding is heavy enough to pose danger to the patient’s life. Some of the commonly looked-for signs include:

• Acne
• Abnormal hair growth on the face or body
• Obesity
• Bleeding points under the skin, nails or gums
• Thyroid enlargement or signs of thyroid disease
• Milky discharge from the nipples

Diagnosis

The cause of menorrhagia is sought by a careful history of additional symptoms, and a physical examination, followed by blood tests to evaluate hormonal levels, other possible contributing factors, pelvic infection or bleeding disorders. Cultures may be taken if there is any suspicion of pelvic infection. Pelvic ultrasound and other imaging procedures may be needed to confirm the diagnosis.

Treatment

The treatment of menorrhagia depends upon many factors, such as:

• Desire for childbearing
• Presence of pelvic disease such as endometriosis, ovarian cysts or fibroids
• Presence of pelvic infection
• The current health status of the woman
• How the menorrhagia affects your daily life

Treatment commonly starts with treating all contributing or causative medical conditions, such as bleeding disorders, thyroid disease or hormonal imbalances.

If not controlled by these, menorrhagia is treated with drugs including:

• Non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen, or naproxen
• Mefenamic acid, an NSAID which reduces menstrual bleeding
• Tranexamic acid which regulates menstrual bleeding without any hormonal intervention
• Birth control pills which help to make periods regular, reduce the blood loss and also the pain of periods
• Oral progesterone 10 days each cycle, to prime the uterus and prevent heavy bleeding
• Progesterone IUD to lighten menstrual blood flow. This can cause cessation of periods in some women as long as the IUD is in place
• Iron supplements if your blood counts are on the lower side

Surgical treatment may include:

• Dilatation and curettage, a scraping away of the uterus lining to check for hormonal imbalance and to reduce the endometrial thickness, as well as immediately reducing the bleeding for the current cycle
• Fibroid surgery, either removal of the fibroid or of the uterus, depending on your desire for childbearing and your age
• Other fibroid surgeries include embolization of the uterine arteries to cut off the fibroid’s blood supply, thereby shrinking it, and ultrasound ablation or removal of the fibroid using ultrasound energy
• Endometrial ablation/ endometrial resection refers to various techniques to achieve permanent removal of the uterine lining without removing the uterus or ovaries. This often lightens the periods. This is only suitable for women who are willing and able to practice reliable contraception till menopause as the thinned out uterine lining cannot support a pregnancy successfully.

Hysterectomy is the procedure in which the uterus is removed. It is a major procedure requiring hospitalization but completely ends periods, and may be a last resort in intractable menorrhagia.