Conditions Heavy menstrual bleeding

Many women have pain, cramps and irregular or heavy bleeding during their period. If pads or tampons often need changing after just 1 to 2 hours or menstrual cups need to be emptied after a few hours, the menstrual bleeding is probably heavier than normal. If the bleeding interferes with daily life or if the loss of blood results in iron deficiency or anemia, this is referred to heavy menstrual bleeding (hypermenorrhea).

Around 10 in every 100 women experience hypermenorrhea. If menstrual bleeding lasts longer than 5 to 7 days, it is considered prolonged bleeding (menorrhagia). Both often occur together.

Some women with heavy menstrual bleeding cope well without treatment. However, if the bleeding causes iron deficiency or impacts life significantly, it can be relieved with drugs. Some causes of heavy menstrual bleeding require surgery.

Women normally lose about 60 milliliters of blood during their period. That is the equivalent of about one and a half shot glasses. With this type of flow, it takes about 4 hours until a pad or tampon of normal size has to be changed. However, these are averages. In reality, bleeding is usually heavier on the first two days of the period and lighter after that. As a result, the amount of blood that is lost during a period may seem greater at times.

If a woman regularly loses more than 80 milliliters of blood in total during her period, gynecologists describe this as heavy menstrual bleeding.
The following signs may indicate this condition:

• Tampons or pads regularly need to be changed after just 1 to 2 hours. A menstrual cup has to be emptied after only a few hours.
• The woman feels weak and lethargic during her period.
• The menstruation blood contains many thick clots.

The upper layer of the uterine lining is shed during a menstrual period. The uterus (womb) contracts at this time to help the upper lining to detach. It can then be expelled together with some blood. If the uterus does not contract effectively, the lining does not detach as easily, resulting in heavier bleeding that often lasts longer too. The most common reason for this is the presence of large, benign tumors such as fibroids or endometrial polyps. Polyps form in the endometrium (uterine lining), while fibroids form in the muscle layer of the uterus.

Other possible causes of heavy menstrual bleeding are:

• Hormonal changes: This may be the case, for example, in girls during their first few periods or in women following the birth of a child or in the years leading up to menopause.
• Contraceptive copper coil: This usually causes heavy bleeding because the uterine lining becomes locally inflamed as a reaction to the coil and small superficial blood vessels may become irritated. Having a hormonal coil fitted may also initially result in heavier bleeding.
• Adhesions or inflammation in the uterus or fallopian tubes: Adhesions may be present from birth or may occur as a result of surgery or severe endometriosis. Malignant growths, such as uterine or cervical cancer, only cause heavy menstrual bleeding in rare cases.
• Certain underlying illnesses: These include, for example, hormone disorders, thyroid diseases and diseases of the heart, kidneys or liver. However, these are rare causes of heavy menstrual bleeding.

Sometimes, it is impossible to clearly identify the cause.

If a woman loses too much blood during her period, this can cause iron deficiency. Iron is very important for building red blood cells. With iron deficiency, the body is unable to produce a sufficient number of red blood cells. One possible consequence of this is anemia.

Red blood cells transport oxygen to the organs. If there are too few red blood cells, the organs will have a poor oxygen supply. This leads to a feeling of weakness and lethargy. Pallor (paleness) and cold hands and feet are also indications of anemia. With more severe anemia, symptoms such as dizziness, breathlessness and a rapid heartbeat may occur, especially after physical exertion.

Some women who are trying for a baby wonder whether heavy menstrual bleeding can make pregnancy more difficult or impossible. There is no one general answer to this question, however, as it depends on what is causing the heaving bleeding. It is helpful to seek medical advice on this matter.

For the purpose of diagnosis, it is firstly important to find out how much blood is being lost during menstruation. While the amount of blood cannot be precisely determined, it can nonetheless be estimated. A good indicator is the number of pads or tampons that are needed on different days during the period or the frequency with which a menstrual cup has to be emptied. It can be useful to note these numbers down over one or two months.

The uterus is usually examined first to clarify the cause of heavy menstrual bleeding. For this purpose, the doctor palpates the uterus and carries out an ultrasound examination. A hysteroscopy (internal examination of the uterus) is sometimes also recommended. For this procedure, a small camera is inserted into the uterus.

A blood test is used to check whether anemia has developed as a result of the heavy menstrual bleeding. If a hormonal imbalance is suspected, the levels of the hormones that influence the lining of the uterus and the menstrual cycle can also be determined.

In addition, the personal situation and type of symptoms can give important indications about possible causes. Patients with heavy menstrual bleeding should therefore also talk with their doctor about existing conditions, diseases in the family, any medication they are taking and any psychological stress they are under.

Various treatment options are available, depending on the cause:

• Medication: Drugs containing the active agent tranexamic acid decrease the tendency to bleed. Many women also taken painkillers such as ibuprofen or diclofenac to treat pain or cramps and these may also reduce bleeding slightly. These drugs are classed as non-steroidal anti-inflammatory drugs (NSAIDs). Acetylsalicylic acid (ASA) is not suitable for treating heavy periods because this active agent prevents clotting and may therefore increase bleeding.
• Hormonal treatment: Progesterone tablets and contraceptives like the pill or hormonal coil make bleeding lighter by inhibiting the growth of the uterine lining.
• Surgery: If symptoms are severe and the woman is not hoping to become pregnant, the lining of the uterus can be removed or ablated, i.e. destroyed (endometrial resection or ablation). A more extensive surgical intervention is the removal of the uterus (hysterectomy). This is only considered for very severe and debilitating symptoms. Fibroids, polyps or other benign proliferations in the uterus can also be surgically removed.

The treatments considered depend, for example, on whether the woman is hoping to become pregnant in the future. This is because the most effective treatments reduce the possibility of becoming pregnant – either temporarily as in the case of the contraceptive pill, for example, or permanently in the case of a hysterectomy. All treatment options, including the pill, painkillers or surgery, have both benefits and drawbacks. Because heavy menstrual bleeding is not an emergency, there is always time to research all of the options and to weigh up the advantages and disadvantages of each.

The decision aid from gesundheitsinformation.de can help you choose an appropriate treatment.

It may also be useful to seek a second medical opinion. In fact, a woman is legally entitled to a second opinion from an expert if she is advised by her doctor to have a hysterectomy.

Many women with heavy menstrual bleeding feel groggy and tired during and immediately after their period. If these symptoms are very severe, they may interfere with daily life – at home or at work. Even social activities and hobbies that are otherwise fun can be stressful at that time.

The need to frequently change pads, tampons or the menstrual cup during the night affects a woman’s sleep. Heavy menstrual bleeding can also be accompanied by abdominal pain.

However, heavy menstrual bleeding is not only difficult from a physical point of view. Many women find it embarrassing. It can also be a source of distress, for instance, during sex. Some women also experience anxiety due to heavy menstrual bleeding.

However, many women affected by heavy menstrual bleeding develop coping strategies over time. For example, they make sure that they are always close to a toilet on days when bleeding is especially heavy or they use a combination of tampons and pads or period underwear.