Heavy menstrual bleeding

Heavy menstrual bleeding is defined as losing 80ml or more in each period, having periods that last longer than 7 days, or both. Most women have a good idea of how much bleeding is normal for them during their period and can tell when this changes.

A good indication that your periods are heavy is if you:

• are having to change your sanitary products every hour or 2
• are passing blood clots larger than 2.5cm (about the size of a 10p coin)
• are bleeding through to your clothes or bedding
• need to use 2 types of sanitary product together (for example, tampons and pads)

In about half of women with heavy menstrual bleeding, no underlying reason is found. But there are several conditions and some treatments that can cause heavy menstrual bleeding.

Some conditions of the womb and ovaries can cause heavy bleeding, including:

• Fibroids or endometrial polyps - non-cancerous growths in the womb (uterus). Fibroids are usually bigger than polyps.
• Endometriosis - when the cells that line the inside of the womb (endometrium) are present outside the womb, such as on the ovaries or fallopian tubes.
• Chronic pelvic inflammatory disease - an ongoing infection in the pelvic area of the body.
• Polycystic ovary syndrome (PCOS) - a condition of having multiple cysts (small, non-cancerous lumps) in the ovaries
• Very rarely cancer of the womb.

There are other conditions, and medical treatments, that can cause heavy periods. Your doctor will ask questions related to your medical history and medication you are taking, to find out why you may be having heavy periods.

A GP will start by asking you about your heavy bleeding, any changes to your periods and any other symptoms you have, like bleeding between your periods or period pain. All women who have heavy periods should be offered a blood test to check for iron deficiency anaemia. If anaemia is detected, your doctor may advise iron supplements and you should eat an iron-rich diet. You should also keep a menstrual cycle calendar, especially noting the days when you are experiencing heavy bleeding.

The GP may also suggest a physical examination or refer you for further tests to try to find out if there’s an underlying cause for your heavy periods.

Further tests may include:

• other blood tests
• an ultrasound scan
• a hysteroscopy - where a narrow telescope with a light and camera at the end is passed into the womb through the vagina to examine the inside of the womb

We usually ask you to try this treatment at least while you wait for arrangements to be made for you to receive other treatment, such as ‘IUS’ listed below, as they are generally safer than some of the other choices. If you and your doctor are happy with how the tablets are reducing your bleeding and you do not have any of the side effects, you can take these tablets for as long as you need them.

There are different types of tablets available:

Mefenamic acid (a non-steroidal anti-inflammatory drug NSAID)

This tablet can reduce your blood loss by up to one half and might also help with your period pain. You take the tablet 3 times a day starting on the first day of your period. You may also take paracetamol with these. This is a safe tablet but if you have asthma or stomach ulcers it may not be the most suitable treatment for you. The doctor will discuss this with you.

Tranexamic acid

This tablet can reduce your blood loss by up to one half. You can take two tablets 3 times a day starting on the first day of your period and continue whilst your bleeding is heavy. If your bleeding is very heavy then the dosage may be increased. This is usually for 3 to 4 days. These tablets are safe but will not be suitable if you have had a thrombosis in the past (blood clot in a blood vessel). Some people may experience mild side effects with this tablet such as an upset tummy and mild skin rash. The doctor will discuss this with you.

IUS: Intrauterine System (Mirena / Levosert)

This is the first line of treatment for women with heavy menstrual bleeding, as recommended by NICE (national guidelines).

This small device is a type of ‘coil’ which the doctor puts into your uterus (womb). The IUS releases a small amount of a progesterone hormone into the uterus. It is a very effective contraceptive and will stop you from becoming pregnant whilst reducing your blood loss. Once the IUS has been fitted most women have a large reduction in blood loss after 3 months and some will stop having periods. A common problem with this coil can be prolonged irregular bleeding in the first 3-6 months. If this does become a problem for you we ask that you wait at least 6 months as your bleeding often settles. Most women are very happy with this treatment and do not need any further treatment for their bleeding. Other mild effects which do not usually last longer than 6 weeks include:

• headaches
• cysts on the ovaries
• water retention
• breast tenderness

There is a small chance that the coil may fall out if your bleeding is very heavy and can happen without you noticing, so we ask that you check your coil threads. IUS will need to be changed by a healthcare professional every 5 years unless you are close to the menopause, when it can be left in for longer.

Progestogen tablets

These hormone tablets are usually taken 2 or 3 times a day from day 5 to day 26 of your cycle. They mimic the progesterone produced by the ovaries after ovulation. Sometimes you may be advised to take the tablet daily throughout your cycle without a break. These tablets are safe but some women have side effects such as bloating, headaches, weight gain, breast tenderness or acne.

Combined contraceptive pill

This tablet can reduce your blood loss by up to one half and might also help with your period pain, as well as stopping you from getting pregnant if taken correctly. If you are over the age of 35 years and smoke or suffer from migraines, thrombosis or heart disease these tablets will not be suitable for you. The doctor will discuss this with you.

GnRH agonist injection or nasal spray

(Decapeptyl / Prostap / Nafarelin acetate spray)

This is often used for bleeding that doesn’t stop despite the use of the above-mentioned treatments. They are also used in the presence of uterine fibroids. This medication will help to reduce the size of the fibroids and is often given 3 months before operations to remove uterine fibroids as it can make the operation simpler and shorter. They will also stop your periods. This medication has side effects of making you feel menopausal.

Endometrial Ablation and Endometrial Resection

These procedures involve destroying the inner layers of your uterus, known as the endometrium, using either heat or electrical energy. Women usually have this procedure in the outpatient clinic, or come to hospital for the day to have it done in under anaesthetic. Most women are fully recovered the day after.

This procedure leads to reduced or normal bleeding for most, but for some women their periods may stop altogether. This treatment is only suitable if you are sure you do not want to become pregnant in the future. Pregnancy following this procedure is rare but as it can occur you must continue to use an effective method of contraception.

The procedure involves passing an instrument into your vagina, through the cervix and into the uterus. The device then releases the heat or electrical energy to destroy the endometrium. It is normal to feel some strong period-like cramping pains after the procedure. This discomfort may be relieved by taking painkillers and using heat pads. The risks from this procedure are rare.

Uterine Artery Embolisation (UAE)

If your heavy periods are caused by fibroids, UAE may be an option. This involves blocking the blood vessels that supply the fibroids, causing them to shrink. It’s carried out under local anaesthetic, so you’ll be awake but the area being treated will be numbed.

Under X-ray guidance, a small tube is inserted into the large blood vessel in your thigh. Small particles are then injected through the tube to block the arteries supplying blood to the fibroid.

Myomectomy

Myomectomy is another treatment option for heavy periods caused by fibroids. It involves surgery to remove fibroids from the wall of your womb. It may be considered as an alternative to a hysterectomy if you’d still like to have children. But a myomectomy isn’t suitable for all types of fibroid. Your gynaecologist can tell you whether the procedure is suitable for you based on factors such as the size, number and position of your fibroids.

Hysterectomy

This is an operation to remove the uterus (womb). This means that you will no longer have periods or be able to become pregnant. You should have a thorough discussion with your gynaecologist about the benefits and disadvantages of the procedure, and this procedure should only be considered after other options have been tried or discussed first. A hysterectomy is generally a safe operation but 1 in 30 women will have a complication during or after the operation.

These include:

• bleeding
• infection
• damage to the bladder or bowel
• blood clots in the legs or lungs
• incontinence of urine and/or frequently emptying your bladder
• difficulty emptying your bladder

There are different types of hysterectomy and your doctor will explain which type of hysterectomy is the best choice for you.

If your periods are heavy but do not affect the way you live you might choose not to have any treatment at all. However, if the cause of your heavy period is not treated, continued heavy periods over a length of time could lead to you having a very low blood iron level (anaemia) which can lead to dizziness, breathlessness, tiredness and occasionally sudden collapse that may require a blood transfusion.

Gynaecology Ward - B11
Telephone: 01709 424349