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Heavy Unscheduled Bleeding - Causes and Treatment

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Heavy Unscheduled Bleeding - Causes and Treatment

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Heavy and unscheduled menstrual bleeding can affect the quality of a woman's life and affect her physically and emotionally. Learn about the common causes and treatment options for severe, painful, and irregular menstrual bleeding.

Written by

Dr. Uzma Arqam

Medically reviewed by

Dr. Anuthanyaa. R

Published At June 7, 2018
Reviewed AtApril 25, 2023

Introduction:

Menstrual bleeding affects the quality of a woman's life and impacts her physically, emotionally, and socially, with or without mild to severe signs and symptoms, and it needs attention. Mostly longer, anovulatory cycles have been observed at and after puberty, whereas frequent and short interval cycles are seen in older women.

What Is Menorrhagia?

Menorrhagia is the cause of around 20 % of gynecologist referrals to hospitals where one in 20 ladies of reproductive age consults a GP (general practitioner) with heavy bleeding. 20 % of ladies have a hysterectomy (removal of the uterus) before 60 years of age due to heavy bleeding.

If periods are unacceptably heavy with or without symptoms, that is, there may or may not be clotting and flooding (not necessarily more significant than 80 ml per cycle), then they need investigations and treatment to prevent further complications like anemia, endometrial hyperplasia, and endometrial cancer.

What Are the Causes of Heavy Bleeding?

  1. Dysfunctional Uterine Bleeding (DUB) -Most women with heavy bleeding are classified as DUB. This is without any uterine or pelvic pathology, an absence of pregnancy, or any medical or systemic disease. It is a diagnosis of exclusion. A woman of reproductive age can be treated easily, even with superficial investigations and history. DUB is abnormal bleeding due to the odds ratio of prostaglandin and inflammatory mediators, causing excessive fibrinolysis, defective local factors, and defect in the endomyometrial junctional zone.
  2. Local Pathology - Heavy prolonged cycles with or without clots could be due to some local pathology like submucous fibroid (can increase blood loss to 200 ml per cycle), adenomyosis, cervical pathology present or treated, pelvic infection, endometrial or uterine polyp, endometrial hyperplasia, etc.
  3. Unscheduled Bleeding With the Use of Oral Contraceptive Pills or After Taking or Skipping Hormones - This bleeding or spotting causes a lot of stress as medications used for heavy bleeding themselves cause spotting and unscheduled bleeding as a side effect.
  4. Medical Disorders - Medical disorders like endocrine problems, thyroid abnormalities (hypothyroidism), bleeding disorders (Von Willebrand), thrombocytopenia, coagulation disorders, and Cushing syndrome also cause uterine bleeding.

What Is Dysmenorrhea?

Pain during menses (dysmenorrhea) is unacceptable, mainly in the first two days of bleeding. The following are the causes of dysmenorrhea,

  • Idiopathic: It occurs mainly in teenage girls, mostly in ovulatory cycles. It might be due to oversensitivity to prostaglandins and overproduction of inflammatory mediators, their local side effects, genetic, psychological causes, or neuropathic dysregulation.

  • Secondary: It is due to an underlying cause or pathology. It could be fibroids, intrauterine contraceptive devices, cervical or uterine pathology, pelvic inflammatory disease, previous surgery (with or without postoperative adhesion), endometriosis, adenomyosis, congenital pelvic abnormalities, Asherman syndrome, etc.

How Is Heavy Unscheduled Bleeding Diagnosed?

  1. A detailed history (gynecological, medical, drug, obstetrical, hormonal, contraceptive, or drug intake).

  2. Examination (generalized and local) - Sometimes, hysteroscopic and laparoscopic tests help a lot to exclude pathologies.

  3. A complete blood count is a preliminary test to check for anemia and platelet count.

  4. Thyroid function test.

  5. Coagulation profile only indicated if having a history or symptoms.

  6. Sexually transmitted disease screening in case of a history of infection only.

  7. Transvaginal scan for endometrial thickness, polyp, fibroid, endometriosis, congenital abnormalities, or other local pathology.

  8. Endometrial biopsy is taken in women aged 40 years with irregular, continuous, heavy, unscheduled, or erratic menses. The biopsy could be a Pipelle endometrial biopsy or hysteroscopic biopsy.

  9. Laparoscopy is advised for women with severe, unbearable, painful periods with abnormal ultrasound findings, medical treatment failure, or along with suspected infertility.

What Is the Treatment for Heavy Unscheduled Bleeding?

For managing any of the conditions mentioned above, the patient's wish and convenience are crucial. Following are the treatment modalities:

A. Medical Treatments:

  1. Prostaglandin Synthesis Inhibitors- For example, the intake of Mefenamic acid (Ponstan) during bleeding reduces bleeding by around 30 % to 40 %. Although it is helpful to reduce pain during periods, it can cause digestive system disturbances in 50 % of the patients.

  2. Antifibrinolytics- Tranexamic acid, if taken during bleeding, can reduce bleeding by up to 50 %, especially in the case of DUB and IUCD related unscheduled or irregular bleeding. It is suggested while waiting for the laboratory results or when the cause is still unknown.

  3. Progestogen- It is given cyclically on specific days of the menstrual period and then stopped for five days to get a withdrawal bleed. This way, it regulates the cycles and reduces unscheduled bleeding.

  4. Combined Oral Contraceptive Pills- Normally, oral contraceptives are given for three cycles to regulate cycles and reduce unscheduled and painful bleeding in patients with low-risk factors like youngsters, slim ladies, and without any chronic conditions like obesity, hypertension, diabetes, migraines, history of venous thromboembolism, or systemic lupus erythematosus. It reduces the bleeding by around 40 % and treats painful menses. Combined oral contraceptives have multiple possible but rare side effects like mood variations, high blood pressure, unscheduled bleeding, migraines, stroke, breast, endometrial cancer, etc.

  5. Mirena (Intrauterine Hormone-Releasing Device)- It can be safely used for three years without side effects. It reduces period bleeding gradually in six months. Women who use this get scanty periods, and a few of them get amenorrhea in six months. Initially, it can give symptoms of unscheduled bleeding, lower abdominal pain, breast tenderness, etc. Mirena is advised for patients with typical endometrial hyperplasia (diagnosed on biopsy) and patients who refused hysterectomy after proven atypical endometrial hyperplasia (having high risks of future endometrial cancer).

  6. GnRH (Gonadotropin-Releasing Hormone) Analogs- It can reduce menstrual bleeding and even stop it, but it causes postmenopausal symptoms to occur. It can cause bone pain in three months and bone loss if used for more than 6 to 12 months. It is primarily used in severe painful periods that do not respond to other medical treatments.

  7. Vitamin B and Magnesium Supplementation- These are also advised for painful menses.

  8. Painful menses can be treated by treating the cause and pain with proper analgesia.

  9. Anemia is to be treated by iron supplementation and an iron-rich diet.

B. Surgical Treatments:

If the patient does not respond to medical treatment, surgical treatment options are advised.

  1. Endometrial Ablation- Advised to patients who have already completed giving birth to children, need contraception and sterilization, do not want to remove the uterus, or are not fit for surgery. It is a short-term procedure. 30 % of the patients are satisfied with the procedure (destruction of endometrium down to the basalis layer). Around 80 % of the patients will significantly improve. Chances of infection, uterine perforation, and failed procedure are there. But, the main drawback is the need for repeat procedures as most patients get benefitted temporarily compared to hysterectomy (permanent relief). The procedure needs general anesthesia and a short hospital stay. Many types of ablations are available like microwave, thermal, balloon, NovaSure, etc.

  2. Hysterectomy- Hysterectomy is advised to patients who did not respond to any treatment, completed family, fit for surgery, and in elderly women with atypical endometrial hyperplasia (biopsy proved). Typically, patients are advised to remove ovaries and tubes, especially in patients aged more than 40 to 45 years with proven atypical endometrial hyperplasia due to a high risk of ovarian cancer in the future. Before surgery, the patient needs to be assessed by an anesthesiologist for complications during surgery and risk factors for venous thromboembolism during and post-procedure.

Conclusion:

In short, heavy, irregular, unscheduled painful vaginal bleeding needs to be investigated and treated according to the patient's need, wish, and convenience to improve the quality of life and to prevent long-term consequences like endometrial cancer.

Frequently Asked Questions

1.

What Is the Treatment of Dysmenorrhea?

The treatment to manage symptoms of dysmenorrhea includes -
- Medicines include nonsteroidal anti-inflammatory medications or NSAIDs, such as Ibuprofen (to reduce pain), oral contraceptives (ovulation inhibitors), and progesterone (hormone treatment).
- Diet changes include increased protein caffeine intake and decreased sugar intake.
- Vitamin supplements.
- Regular exercise.
- Heating pad across the abdomen.
- Hot bath or shower.
- Abdominal massage.
- A surgical procedure, a hysterectomy, can be done to remove the uterus.

2.

How Much Pain DoesDysmenorrhea Cause?

The menstrual cramps or dysmenorrhea cause a throbbing or cramping pain in the lower abdomen. Sometimes the pain can be similar to labor pain. However, for some women, the pain is merely annoying.

3.

How to Diagnose Dysmenorrhea?

Healthcare professionals can diagnose dysmenorrhea after taking a complete medical history and doing a complete physical and pelvic examination of the patient. Along with that, some additional tests can also be done, which include -
- Ultrasound (sound waves are used to create the uterus, cervix, fallopian tubes, and ovaries. Other imaging tests such as MRI or magnetic resonance imaging and CT or computed tomography can also be performed).
- A laparoscopy is performed to check the pelvic and abdomen area for abnormal growth.

4.

Is Having Dysmenorrhea Normal?

Dysmenorrhea is extreme pain before or during periods, and it can be a sign of a serious health condition that needs to be treated. Some women feel pain before or during menstruation which is termed primary dysmenorrhea, and in cases where the periods become painful later in life is termed secondary dysmenorrhea. The pain caused by both types is excessive and needs to be treated.

5.

Does Dysmenorrhea Cause Infertility?

Endometriosis is one of the main causes of secondary dysmenorrhea, which can result in a marked reduction of the quality of reproductive life, leading to infertility and pelvic pain. In this condition, the tissue that normally lies in the uterus grows outside, which has to be surgically treated. Endometriosis can influence fertility in various ways, such as -
- Distorted anatomy of the pelvis. 
- Scarred fallopian tubes.
- Inflammation of the pelvic structures. 
- Altered immune system functioning.
- Changes in the hormonal environment of the eggs. 
- Impaired implantation of a pregnancy.
- Altered egg quality.

6.

Which Sleeping Position Is Best for Dysmenorrhea?

The best position to sleep during menstrual cramps is the fetal position. It is similar to how the fetus in the womb is present. First, roll to the side and tuck your arms and legs, which will take off the pressure from the abdominal muscles.

7.

Is Menorrhagia Life-Threatening?

Heavy menstrual bleeding can be serious if a person loses too much blood. Women with menorrhagia usually bleed for more than seven days. If the bleeding goes on for more than seven days per period and the patient needs to change pads every hour, they should consult the doctor.

8.

Is It Possible to Cure Menorrhagia Naturally?

Menorrhagia can be managed naturally with -:
- Eating fresh fruits and vegetables.
- Taking supplements such as iron and calcium supplements.
- Staying hydrated.
- Managing sugar intake.
- Adding omega three in the diet, such as fish and flaxseed oil.
- Avoiding stress.

9.

What if Menorrhagia Is Left Untreated?

Untreated menorrhagia or prolonged menstrual bleeding can lead to various health conditions. One of the most common complications of untreated menorrhagia is anemia. This impact the daily life of the patient as they will feel tired or weak every time.

10.

Can Menorrhagia Lead to Weight Loss?

Menorrhagia does not cause weight loss. However, reducing weight can help in conditions like menorrhagia. Women who are obese tend to experience periods longer than seven days and with blood clots. In addition, losing weight can reverse this effect and helps in dealing with this condition.

11.

What Vitamins Are Helpful in Heavy Periods?

Heavy periods or bleeding can lead to conditions like anemia. Various vitamin supplements can be given to the patient to manage this condition, including -
 
Iron supplements help to rebuild the iron stores of the body. Daily multivitamins include folic acid, vitamin C, vitamin B12, and other vitamins in a low amount that helps stimulate red blood cell production.

12.

What Number of Pads Are Normal for a Period per Day?

It is difficult to describe the average number of pads per day. However, the usual amount of blood loss per day during menstrual cycles is 10 to 35 milliliters, and each pad can soak around five milliliters of blood, which means it is fine to use around one to seven pads per day. Moreover, bleeding through two or more pads per hour indicates a health condition.

13.

What Is the Reason for Heavy Periods With Clots?

In some cases, women experience high levels of estrogen and low levels of progesterone hormone, which can cause heavy periods with blood clots. This irregularity in hormone levels leads to the thickening of the uterine lining. And when this lining sheds during periods, it causes heavier blood flow with large blood clots.

14.

What Is the Cause of Long Periods?

Long periods indicate various underlying medical conditions, including -
- Certain nonhormonal medications, such as antidepressants.
- Hormonal birth control.
- Abortion (usually first period after the abortion).
- Miscarriage.
- Uterine polyps or fibroids.
- Hypothyroidism (low thyroid hormone production).
- Endometriosis.
- PCOS (polycystic ovary syndrome occurs when ovaries produce an excessive amount of male sex hormones called androgens).
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Dr. Uzma Arqam
Dr. Uzma Arqam

Obstetrics and Gynecology

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menorrhagiaabnormal uterine bleedingintermenstrual bleeding
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