Menorrhagia

Menorrhagia or Hypermenorrhea implies an irregular heavy and long-span menstrual period at frequent intervals. In a normal menstrual cycle, bleeding lasts for 5 days average accompanied by a blood flow of 25 to 80 ml. In menorrhagia, the bleeding continues for more than 7 days and the blood flow is more than 80 ml. Also, it occurs at generally 28 days against a normal menstrual cycle which is 21 to 35 days.

Symptoms of Menorrhagia

• the menstrual flow has large blood clots
• sanitary protection has to be changed in the night
• continuous pain in the lower abdomen in the menstrual period
• necessity of double sanitary protection to control the menstrual flow
• fatigue, tiredness or shortness of breath
• menstrual period continues for more than a week
• menstrual flow soaks tampons each hour for many continuous hours
• anemia

Causes

• high level of prostaglandins (i.e. chemical substances that assist in controlling the muscle contractions in the uterus)
• abnormal pregnancy (ectopic, miscarriage)
• kidney, liver or thyroid disease
• uterine fibroids
• high level of endothelins (i.e. chemical substances that assist the blood vessels to dilate)
• pelvic inflammatory disease
• platelet or bleeding disorders
• hormonal imbalance (generally in adolescents having the menstrual period for the first time or in women near menopause)
• systemic disorders like hypothyroidism and blood clotting disorders (von Willebrand's disease or thrombocytopenia)

Diagnosis
The doctor checks the womb and the ovaries internally. At times, a sample of the lining of the womb is taken during vaginal examination. A blood test is done to ascertain anemia and other tests like thyroid and reproductive hormones. A smear test is done to detect any possibility of cancer of the neck of the womb to prevent any development. The Body Mass Index has to be considered. The reason is that body fat is crucial regarding metabolism of steroid hormones. The tongue has to be examined for any paleness and the nails for koilonychia. A bimanual examination may reveal a bulky or grossly enlarged uterus or fixation of the uterus. Any endocrine abnormality or bruising should be noted. It is confirmed that the cervical smear is proper. Vaginal ultrasound and Endometrial biopsy may also be performed.

Treatment

• a combination of estrogen and progestogen is used to decrease bleeding and regularize it
• Mefenamic acid (ponstan) reduces bleeding and kills pain
• Tranexamic acid (cykloklapron) affects blood clotting and decreases bleeding by 50%. The side-effects are leg cramps, nausea and greater risk of deep vein thrombosis
• the intra-uterine contraceptive device (Mirena) causes levonorgestrel to be introduced in the uterus, which decreases the amount of thickening in the lining of the womb before menstruation. This can decrease or cease the periods
• iron supplements are taken to overcome anemia
• A single-rod progestin implant called Implanon is inserted under the skin in the upper inner arm. This can control bleeding up to three years. When pregnancy is desired, the implant can be removed
• Medroxyprogesterone acetate is injected deep into the muscle after every three months into the buttock or upper arm. A similar preparation is also used subcutaneously
• in Endometrial ablation, the lining of the uterus is removed by a depth of five or six millimeters and this results in ceasing periods
• in Hysterectomy, the uterus is removed to stop periods permanently. In many cases, the cervix is also removed

The choice of surgical treatment depends on the uterine size and the patient's wish to retain the uterus. If the uterus is less than 10 weeks size, the first-line treatment is Endometrial ablation. During this, the full thickness of the endometrium and the superficial myometrium and the basal glands are removed. The uterus is retained. In case the uterus is more than 10 weeks and the woman desires to retain the uterus, then uterine artery embolisation or hysteroscopic myomectomy are the two choices. When the woman does not desire to retain the uterus, then hysterectomy is the option. It may be vaginal or abdominal with retaining of ovaries.

Abnormal Vaginal Bleeding
This may take place between normal menstrual bleeds called intermenstrual bleeding or may be heavy menstrual bleeding i.e. menorrhagia. This may be caused by many factors like sexual abuse, injury to the vagina or vulva, ectopic pregnancy or miscarriage, cancer of the uterus or cervix, infection of the uterus or hormone imbalances.