HEAVY, PROLONGED MENSTRUAL PERIODS

Women with no previous gynaecological problems, and no reason to think they have fibroids, polyps, a pelvic infection or endometriosis, are in a quandary. Are these bleeding episodes a cause for concern? Or are they a normal response to changing levels of sex hormones, perhaps associated with menopause-related changes, or to something else? Most women experience irregular menstrual periods for between two and seven years prior to menopause, although the range is a few months to eleven years. This can be a stressful time because of concerns about the cause of the bleeding.

Doctors classify excessive heavy bleeding (menorrhagia) as the repeated loss of more than 80 ml of menstrual blood in each menstrual cycle. If this volume is lost consistently during menstruation, women can become anaemic, lethargic and prone to sickness. While this is a concern for health reasons, the social impact is often more worrying still, with the added burden of possibly creating financial difficulties. Some women find they need to plan their activities carefully to minimise the embarrassment of bleeding accidents, or they may take time off work coping with the problem or trying to find out the underlying cause. Kath’s experience of heavy bleeding coincided with a very hot summer. After a couple of bleeding accidents when she ‘flooded’ on her way to, or at, work she took the precaution of wearing dark-coloured clothing that would disguise any such episode, as well as using tampons and sanitary pads of increased absorbency. A number of colleagues unwittingly added to her embarrassment by making disparaging comments about the inappropriateness of her clothing given the sweltering heat. Initially Kath tried to shrug the comments off and joked about getting dressed before the lights came on. But one day she decided enough was enough and, when quizzed about her clothing, she simply said, ‘I’m having a hellish time with my periods at the moment and, believe me, I’ll be celebrating when I can wear white again.’

In normal day to day living, measuring how much blood is lost in a menstrual bleed is virtually impossible. When careful studies are conducted, however, women are found to lose about 35 ml of blood (less than a quarter of a cup) in a cycle on average. Clearly, the 80 ml marker of menorrhagia is set quite high.

The diagnosis of excessive heavy bleeding is usually based on a joint assessment by women and their doctors. Factors taken into account include the number and degree of saturation of pads and/or tampons, the duration of bleeding, and the presence or absence of clots and flooding. This assessment is subjective and various research studies suggest that women may think they are losing more or less blood than is revealed by a careful analysis of sanitary products. In one study, for example, while 59% of women with concerns about menorrhagia were losing more than 60 ml of blood in most cycles, another 20% had average losses of less than 35 ml. Younger women in particular seem to be more likely to regard moderate blood loss as heavy. Reassurance about bleeding patterns, if this is appropriate, or information about how to better organise and cope with tampon and pad use can result in management of the problem without drugs or surgery.

A specific cause for heavy bleeding may never be found, although there is usually much speculation about possible reasons. Fibroids are thought to be the culprit in about a quarter of cases, while in others polyps, endometriosis, polycystic ovaries, abnormalities of the body’s blood-dotting mechanism, chronic liver or kidney disease, ectopic pregnancy, pelvic inflammatory disease, and side-effects from hormone therapies and intra-uterine contraceptive devices are implicated. Where possible, likely causes should be avoided, removed or treated.

Where there is no explanation for recurrent heavy blood loss, doctors usually describe the bleeding as ‘dysfunctional’. Drug therapies or removal (resection) of the endometrium are the usual strategies in trying to correct the problem. If these approaches do not work, a hysterectomy may be the last resort.

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