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Menstrual Problems - Heavy, painful or irregular periods

This page provides some information to help understand the causes, tests and treatments for women with heavy bleeding to help make informed choices.  Women should ask their doctor for more information on any aspect of the information provided here.

Many women think that heavy periods are a normal fact of life – my mum suffered it and I am suffering it’ therefore it is considered a normal part of womanhood. 

Heavy periods are very common in women, and usually are not a sign of anything serious – but they can cause a big disruption to your life. Heavy periods can cause tiredness from low iron in the blood, or less commonly, anaemia (low red blood cells).

Symptoms:  Heavy bleeding is hard to define, but if you have to change tampons or pads many times a day, avoid going out for fear of an “accident” (flooding), have large clots, or have to get up in the night to change pads, then you almost certainly have heavy bleeding.  Heavy bleeding is more common in women who have just started their periods or are coming up to menopause.

Causes:  In most cases there is no cause found for heavy bleeding.  The uterus and ovaries are normal and the female hormones are normal.  Occasionally there is a cause for heavy bleeding and this can include:

  • Fibroids

  • Endometrial polyps

  • Other abnormalities of the lining of the uterus (endometrium)

  • Hormonal problems

Most of these conditions can be diagnosed by careful history and examination by your doctor, sometimes there is also the need to do further investigations/tests.

Your doctor may want to do an internal (vaginal) examination to examine the cervix and to assess the size and shape of your womb (uterus). However, an internal examination is not always necessary, especially in younger women who do not have any symptoms to suggest anything other than abnormal uterine bleeding.

A blood test to check for anaemia is usually performed. If you bleed heavily each month then the iron that you take in through your diet may not be enough to replace the blood that you lose.  Iron is needed to make blood cells and low iron can lead to anaemia which can cause tiredness and other symptoms.

If the internal examination is normal (as it is in most cases), and you are under the age of 40, no further tests are usually needed.  The diagnosis is usually abnormal uterine bleeding and treatment may be started if required. 

Further tests may be advised for some women, especially if there is concern that there may be a cause for the heavy periods other than abnormal uterine bleeding.  If tests are advised then they may include one or more of the following:

Additional blood tests:  If you doctor suspects you have an underactive thyroid gland or a bleeding disorder then more blood tests may be requested.

An ultrasound scan of your uterus: This is a painless test which uses sound waves to create a picture of the structures inside your body.  The ultrasound probe may be placed on your tummy (abdomen) to scan the uterus. A small probe is also often placed inside the vagina to scan the uterus from this angle, giving a clearer picture of the uterus, mild discomfort may be experienced with the internal ultrasound.  The ultrasound scan can usually detect any fibroids, polyps, or other changes in the structure of your uterus.

Internal swabs:  Your doctor may wish to take some swabs from inside the vagina if infection is the suspected cause of the heavy bleeding.  The samples from the swab are sent away to the laboratory for testing.

Pipelle (Endometrial sampling): This is where a very thin sampling probe is passed into the uterus through the cervix to obtain a tiny sample of the uterine lining (endometrium).  Gentle suction is used to obtain the sample and this procedure is usually done without an anaesthetic.  Not all women need to have a pipelle however this is more likely to be done if you are aged over 45 years, have persistent bleeding or have tried treatment without it helping.  The samples are sent away to the laboratory for testing.

Hysteroscopy D&C:  This is where a doctor can look inside the uterus by inserting a thin mini telescope into the uterus via the vagina.  A sample of the lining of the uterus will be taken if needed and sent away to the laboratory for testing.

Hysteroscopy is able to detect fibroids, polyps, or an abnormal thickened lining; polyps and small fibroids may also be removed from inside the uterus during this procedure. The tissue that is removed is also sent to the laboratory for examination.

This procedure is typically done without anaesthetic. You can read more information about the Hysteroscopy procedure.

Treatment: 

Many treatment options are available for the management or control of heavy menstrual bleeding. These include medication, a progesterone-releasing intrauterine device (IUD), destruction of the lining of the uterus and hysterectomy.

If anemia (low iron in your blood) is present your doctor will also need to prescribe an iron supplement.  Iron infusion may also be required for very low iron count and occasionally a blood transfusion may be required.

Medical Therapy

Tranexamic Acid –  this is a non-hormonal form of treatment and is taken as a tablet – typically 3-4 times a day, for 3-5 days during your period.  It is used to stop or reduce heavy bleeding and can reduce the heaviness of bleeding by up to half in some women.  Tranexamic acid decreases the heaviness of bleeding by reducing the breakdown of blood clots in the uterus.  The body typically forms blood clots to stop bleeding and in some women, these blood clots break down causing too much bleeding. 

Non-steroidal anti-inflammatory (NSAID) – this medication is taken as a tablet typically for a few days during each period.   The more commonly available forms of this are ibuprofen or nurofen, which can be purchased from your pharmacy/supermarket; however other types are available that your doctor may prescribe for you. 

This form of medication works by reducing the high level of prostaglandin (hormone) in the lining of the uterus.  Prostaglandins seem to contribute to heavy periods and period pain and this medication also eases period pain as well as reducing the heaviness of bleeding however they do not reduce the number of days the period lasts.

Combined Oral Contraceptives – is a hormonal form of treatment and is taken as a tablet (pill), one per day.  The pill contains the hormones progestogen and oestrogen and is normally used to prevent pregnancy.  Part of the effects of preventing pregnancy includes making the lining of the uterus thinner so that pregnancy cannot occur.  It is the lining of the uterus that comes away every month in the form of the period; a thinner lining can result in reducing the heaviness of the bleeding. 

Oral Progestogen – if you have prolonged bleeding your doctor might start you on oral progestogen (Norethisterone or Provera).

Mirena (Intrauterine Contraceptive Device – IUCD) Mirena is a type of IUCD which is a small device that fits inside the womb (uterus).  Unlike other IUCDs, the Mirena slowly releases a small amount of the hormone progestogen, this is a very small dose and most women have no side effects from this.  Neither you nor your partner can feel the Mirena nor tell it is there except by checking for the threads.  These removal threads come out of the cervix and remain inside the top of the vagina, they don’t hang outside of the vagina.

Mirena reduces period bleeding and pain so most women will have light bleeding or no periods at all.  It is a long-acting treatment, with each device lasting five years, although it can be taken out at any time.  

The Mirena is typically used as a contraceptive device.  It primarily works by thickening the mucus plug, preventing sperm entering the womb and also prevents the egg from implanting in the uterus.  The Mirena also makes the lining of the uterus very thin. Some women who have heavy menstrual bleeding may be eligible for Government subsidy for the Mirena but this depends on your symptoms and either haemoglobin or iron levels.  You GP will be able to advise you if you are eligible. Additional Information on the Intrauterine Device - Mirena

Your GP will be able to advise you on the most suitable option for you and in some situations, the bleeding may be better controlled by a combination of treatments/medication since the various treatments do work differently. Medical management will normally be trialled for 3 months with the recommendation to continue for up to 6 months if there has been some improvement at 3 months.

Day-stay Treatment

Hysteroscopy: Hysteroscopy can be used as a test to help in the diagnosis of abnormal uterine bleeding but is also used in various forms of treatment.  When the doctor is looking inside the uterus with the hysteroscope (thin mini telescope that is inserted into the uterus via the vagina), they can also perform the following methods of treatment:

  • Endometrial Ablation: – this is the where the lining of the uterus (endometrium) is destroyed using laser, heat or freezing.  The aim is to leave very little of the lining tissue; this will heal leaving scarring, which usually reduces or stops menstrual periods.  In some women, bleeding does not stop but is reduced to normal or lighter bleeding.  If this procedure does not control the bleeding, further treatment or surgery may be required.  Endometrial ablation is only performed in women who no longer wish to have children.
  • Polypectomy and Fibroid Resection: - if polyps or fibroids (located within the uterine cavity) are found, a special instrument is passed through the hysteroscope to remove them. 

These procedures will typically be performed as a day procedure, without the need for anaesthetic. There are some situations where sedation (you are awake but drowsy) or local anaesthetic (you are awake but the area being investigated is numb) may be required and this can be arranged on the day.  There are also some situations where the procedure may need to be done under general anaesthetic (you are asleep); if GA is required then a booking on another day may be required.   Recovery time is much faster than with hysterectomy and typically takes about 2 hours. You can read more information about the Hysteroscopy procedure.

Advanced Treatment:

Women with heavy menstrual bleeding related to large uterine fibroids who choose surgical or radiological intervention should have a documented discussion about uterine artery embolisation, myomectomy and hysterectomy.

Fibroid Embolisation: - is a non-surgical method of treating fibroids by blocking the arteries that feed the fibroid. This causes the fibroid to die off and shrink.  The procedure is performed by an Interventional Radiologist using a very fine tube called a catheter. The catheter is inserted into the artery in the groin, with just a small nick in the skin, and guided into the arteries that supply the fibroids using x-ray. A biocompatible material is injected to block all the arteries that supply the fibroids.  Once the procedure is finished the catheter is removed. Patients stay in hospital overnight and generally go home the following day.  Additional information on Fibroids 

Myomectomy: - this is a procedure whereby fibroids are removed but the uterus is saved, especially where fertility is desired. This can be done by hysteroscopy (see previous section), laparoscopy (key-hole surgery) or laparotomy (cut in abdomen). The type of surgery depends on the position and size of the fibroids, and will be discussed by the gynaecologist.  Laparoscopy and laparotomy forms of myomectomy are done under general anaesthetic.  Additional information on Fibroids 

Hysterectomy: - Hysterectomy is the surgical removal of the entire uterus and thus periods stop permanently. There are more side effects and recovery takes longer, and this is recommended only if other methods to control the bleeding have been unsuccessful, however the decision to have a hysterectomy is made by you in consultation with your gynaecologist.    

There are 3 types of hysterectomy and all are done under general anaesthetic:

  • Abdominal hysterectomy – your uterus, cervix, fallopian tubes and ovaries will be removed via an incision in your abdomen.  Typically post-op stay in hospital is 4-5 days.
  • Vaginal hysterectomy – your uterus, cervix will be removed via an internal incision at the top of the vagina.  You will be given the option to have your fallopian tubes and ovaries removed at the same time.
  • Laparoscopic hysterectomy – your uterus is removed via laparoscopic procedure.  A small cut about one centimetre long is made in the belly button (umbilicus) so that the laparoscope (fine tube-like fibre-optic telescope) can be inserted into the abdomen.  Other small cuts are made which allow different instruments to be introduced into the abdomen so that the uterus can be removed. 
  • Hysterectomy specific information.

Your gynaecologist will explain which procedure is the most appropriate in your situation and he/she will explain to you the reasons for this recommendation.


    




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