Heavy Periods

Problems with your Periods Edited excerpts from our book A Gynecologist's Second Opinion by William H. Parker, M.D.

Problem With Your Period

Throughout history, menstruation has been associated with myth and superstition. Menstrual blood was felt to cure leprosy, warts, birthmarks, gout, worms and epilepsy. It has been used to ward off demons and evil spirits. Menstruating women have been separated from their tribes in order to prevent a bad influence on the crops or the hunt. As recently as 1930, the cause of abnormal menstrual bleeding was felt to be an undue exposure to cold or wet just prior to the beginning of the period.

In modern times we have learned that menstruation is the end of the monthly cycle a woman's body goes through if conception has not occured, allowing the uterine lining to start over again for the next cycle. We have made quantum leaps towards understanding the role menstruation plays in preparing a woman's body for reproduction. And we have learned a great deal about the treatment of many of the problems of abnormal periods. Science has thankfully dispelled the myths and superstitions that surrounded menstruation and sexuality, but the mystery and wonder of these processes stays with us still.

Since the days that I studied the female hormone system in medical school, new research has revealed an astonishingly complex system of hormones and nerve transmitter proteins that interplay to regulate the monthly menstrual cycle. The system is balanced, but in certain situations - such as times of stress, when body weight changes, when taking medications - it is easily upset. Once the balance is upset, bleeding can occur that is outside of the normal pattern. Also, cells that form abnormal growths within the uterine lining - polyps, hyperplasia, cancer- can cause bleeding as they develop. In the first part of this chapter, we will deal with the circumstances and solutions for problems with your periods. The second part of the chapter will deal with painful periods and the new ideas and treatments for this common, bothersome and, sometimes, incapacitating problem.

What Kind Of Period Is Normal?

The onset of menstrual periods occurs between the ages of 9-17 with the average age being 13. Adolescents tend to have periods that are far apart and then establish more regularity over the subsequent few years. Most adult women will have a menstrual cycle, measured from the first day of any bleeding to the next episode of bleeding, about every 21-35 days. Although women expect to bleed every 28 days, only 15% of women actually have cycles that length. Bleeding usually lasts 4-6 days with some women bleeding a few days longer or shorter. Most women lose about 6 teaspoons of blood each month. Interestingly, the number of days between periods changes over time, with periods becoming further apart as women reach their forties.

When Is Bleeding Abnormal?

Abnormal bleeding is said to occur if you have a period more often than every 21 days, less often than every 35 days, or if you have bleeding or spotting in between periods. Very heavy bleeding, saturating a pad or tampon every hour or two for more than a few hours, is also abnormal. There are a number of causes of abnormal bleeding, and the good news is that almost all of them are benign and easily treatable. The most common causes are hormonal changes, ovarian cysts, uterine or cervical polyps, overgrowth of the uterine lining cells (hyperplasia), fibroids, and, rarely, precancer or cancer of the uterus. The following sections will explain each of these problems in detail.

What Should Be Done If You Have Abnormal Bleeding During Perimnopuse Or After Menopause?

Presence of the benign tumor in the uterus hinders the placement of eggs. There is high possibility of the egg to get dislocated as a result. This makes successful implantation difficult and leads to infertility.

What Is Hysteroscopy?

This test allows the doctor to look inside the uterus by placing the hysteroscope, a small telescope, through the vagina and into the opening in the cervix. Once inside the uterus, the lining cells can be inspected. Polyps, fibroids, hyperplasia and cancer can all be seen with the hysteroscope. The procedure, called hysteroscopy, can be done in the office in about 5 minutes and usually does not require any anesthesia. The information the doctor can get from this procedure is invaluable. Because many problems can be clearly seen, the diagnosis is often certain. A number of studies have shown that the diagnosis made by hysteroscopy followed by scraping the visualized abnormal area of lining cells is more accurate than when a D&C is performed blindly without the hysteroscope.

Molly's Persistent Bleeding

Molly is a 66-year-old woman who had been having bleeding after her menopause. She had already undergone three D&Cs and a varuety of hormonal treatments, yet the bleeding persisted. Her examination was normal, but I suggested that we do a hysteroscopy in the office. This had never been done, and we really needed to see why the bleeding was not going away. She agreed, and we scheduled it for the next day. After using local anesthesia, the hysteroscope was inserted, and it was immediately apparent that a large polyp was inside the uterine cavity. The polyp was loosely attached to the uterine lining by a stalk, so that it flopped back and forth. Without knowing exactly where it was, the previous D&Cs had missed it entirely. After placing a polyp forceps into the uterus in the exact location of the polyp, the polyp was easy to remove. Another inspection of the uterine cavity with the hysteroscope now showed that the polyp was gone. Molly has not had abnormal bleeding again.

What Is An Endometrial Ablation?

Endometrial ablation is an outpatient surgical procedure used to stop or decrease bleeding from the uterus. The traditional method of performing endometrial ablation uses electrical energy passed into the uterus at the end of a telescope in order to burn and destroy the lining of the uterus The uterus is filled with fluid and the doctor is able to look through the telescope and watch to make sure the entire lining is destroyed. This technique is very effective, but does require special training and skill on the part of the doctor. As a result, many doctors never learned how to perform endometrial ablation and do not offer the procedure to their patients as an alternative to hysterectomy.

Newer methods of ablation have recently been developed that should allow most gynecologists to perform the procedure without involved special training. Some of these devices may even be able to be used in a doctor’s office, avoiding anesthesia and the added costs of a hospital. In addition, neither of the new methods uses fluid to hold the uterus open during surgery and thus avoids the extremely rare chance that extra fluid might get absorbed into the bloodstream and cause complications. One of these methods uses an expandable metal device that is inserted into the uterus like an IUD, Once the device is expanded inside the uterus, a gentle suction pulls the uterine lining close to the instrument and an electrical current burns the lining cells. This procedure only takes 90 seconds and the results have been excellent. Another device circulates hot water inside the uterus to burn the lining cells. This device has been specially engineered to keep the water at a low pressure so that it cannot escape through the tubes. If the device senses a leak it automatically shuts off. Because the water circulates freely throughout the entire uterine cavity, the shape of the cavity will not affect the results. As a result, the device is very effective for women with fibroids, enlarged or abnormally shaped uterine cavities. This procedure takes about 10 minutes and results have been comparable to the other methods. Other devices are in development and, hopefully, endometrial ablation will become more available to women as an alternative to hysterectomy for heavy bleeding.

How Well Dose Endometrial Ablation Work?

After endometrial ablation, the ovaries continue to make normal amounts of hormone, but without lining cells, bleeding cannot occur. In 50% percent of patients, all the lining cells have been destroyed, and these women never have another menstrual period again. In an additional 40% percent of women, a few lining cells have been left behind, and these women will experience a light flow for a few days each month. For 10% of women, no improvement is noted. Still, 90% of the women who have this procedure are extremely happy not to have to tolerate the severe and debilitating monthly bleeding they had previously had. Women who have had an endometrial ablation are among the most satisfied patients in my practice. After surgery, they are able to return to normal activity and life unencumbered by the fatigue and inconvenience associated with heavy bleeding.

Endometrial ablation may only be performed on women who do not wish to have any, or any more, children. Once the lining cells of the uterus are destroyed by the procedure, there is no place for a developing fetus to attach within the uterus. Despite this, it is best to use some form of contraception after the procedure. If some cells remain following endometrial ablation, there exists the rare possibility of pregnancy. In the few cases where pregnancy has occurred, termination of the pregnancy has been recommended. Doctors have been concerned that without adequate cells lining the inside of the uterus, the placenta would grow abnormally, directly into the muscle wall of the uterus and take hold like the roots of a tree. As a result, the placenta would not be able to separate at the time of delivery, and hemorrhage could occur.

What Are The Causes Of Painful Periods (Dysmenorrhea)?

Dysmenorrhea refers to the pain accompanying a period. Most menstruating women have uterine contractions of moderate strength that each last for less than thirty seconds and occur about every 3 to 5 minutes. However, women who experience severe dysmenorrhea have cramps that last up to 90 seconds with only a few seconds of rest in between. And, the strength of the contraction may be up to 5 times greater than normal.

We now know that dysmenorrhea results from the release of a chemical substance, called prostaglandin, from the lining cells of the uterus at the time of the menstrual period. The prostaglandin causes contractions of the muscle wall of the uterus, "menstrual cramps". In fact, if you give prostaglandin to a woman by injection, severe menstrual cramps result. Along the same lines, prostaglandin is now used to help start the contractions of labor in women who, for medical reasons, need to deliver their babies promptly.

Women who have dysmenorrhea have been found to produce more prostaglandin in the lining cells of the uterus than woman who do not have cramps. And, when the increased amount of prostaglandin is released at the time of the period, stronger uterine contractions are the result. As we will discuss, new medications are now available that prevent the formation of prostaglandins in the uterus and thus can prevent or decrease menstrual cramps.

About Your Periods

• What Kind Of Period Is Normal?
• What Makes Your Cycle Regular?
• When Is Bleeding Abnormal?

Hormonal Problems

• Are Adolescents Prone To Abnormal Bleeding?
• Are Adolescents Prone To Abnormal Bleeding?
• Can Your Weight Affect Your Periods?
• Can Changes In The Amount Of Exercise You Do Cause Abnormal Bleeding?
• Can Anorexia Nervosa Interfere With Your Periods?
• Can Any Medications Interfere With The Menstrual Cycle?
• Can Drug Or Narcotic Use Cause Abnormal Periods?
• Can Problems With Your Thyroid Gland Interfere With Your Periods?
• Can Other Hormonal Problems Interfere With Your Periods?
• Can Ovarian Cysts Cause Irregular Periods?
• Can Missing Periods Lead To Any Other Problems?

Treatment For Abnormal Periods

• What Is The Treatment For Abnormal Periods?
• What Is The Treatment If Irregular Bleeding Is Due To Missed Ovulation?
• When Is A D&C Neccesary For Abnormal Hormonal Bleeding?
• Are There Homeopathic Remedies For Abnormal Bleeding Due To Hormonal Causes?
• What Is Polycystic Ovarian Disease (Pco)?
• What Is Premature Menopause?

Menopausal Bleeding

• What Kind Of Bleeding Problems May Develop In Menopause?
• What Should Be Done If You Have Abnormal Bleeding During Perimenopause Or After Menopause?
• What If You Are Bleeding While You Are On Hormone Replacement Therapy For Menopause?

Polyps, Fibroids, Hyperplasia And Cancer

• What Are Uterine Polyps?
• Can Polyps Be Cured?
• What Kind Of Bleeding Problems Can Fibroids Cause?
• What Is The Best Treatment If The Cause Of Bleeding Is Fibroids?
• What Is Hyperplasia (Overgrowth ) Of The Uterine Lining?
• Can Abnormal Bleeding Be A Sign Of Cancer?

Tests For Abnormal Bleeding

• How Do We Find Out What Is Causing Your Abnormal Bleeding?
• When Are Further Tests Needed?
• What Is Hysteroscopy?
• What Happens During An Office D&C?
• What Is An Endometrial Biopsy?
• Can A Sonogram Be Used To Diagnose The Cause Of Abnormal Bleeding?

Treatment For Abnormal Bleeding

• What Is The Best Treatment If The Bleeding Does Not Go Away?
• What Is An Endometrial Ablation?
• When Is A Hysterectomy Neccesary For Abnormal Bleeding?
• What Can Be Done If You Have Uterine Precancer Or Cancer?

Bleeding Problems And Pregnancy

• What If You Are Pregnant And Have Bleeding?
• What Should Be Done If You Are Miscarrying?
• Can Bleeding Mean You Have An Ectopic Pregnancy?
• What Causes An Ectopic Pregnancy?
• How Can The Doctor Tell If You Have An Ectopic Pregnancy?
• What Are The Possible Treatments For An Ectopic Pregnancy?
• What Is The Current Research Regarding Treatment Of Ectopic Pregnancy?

Painful Periods

• How Common Are Painful Periods (Dysmenorrhea)?
• What Symptoms Can Occur With Painful Periods?
• What Are The Causes Of Painful Periods (Dysmenorrhea)?
• How Is The Diagnosis Of Dysmenorrhea Made?

Treatment For Painful Periods

• What Is The Best Treatment For Painful Periods?
• Can Homeopathics And Herbal Therapies Be Used For Period Pain?
• Can Acupuncture Be Used To Treat Painful Periods?
• Can Surgery Help Period Pain?
• What If Your Pain Occurs In The Middle Of The Cycle?

Coping with Heavy Bleeding

What is heavy bleeding?

Excessive menstrual bleeding affects one in five women. This leaflet describes some of the problems women experience with heavy bleeding, and suggests ways of coping. It explains the treatments which your doctor or gynaecologist is likely to offer, and also mentions complementary therapies. The leaflet aims to help women make informed decisions about the treatment choices for heavy bleeding.

The amount of blood lost in each period varies enormously from individual to individual. Some women lose a few teaspoonfuls and hardly notice their periods, while other women regularly lose large volumes of blood. Because of this wide variation it is impossible to define a 'normal' period in terms of the amount, length, and frequency of bleeding. A heavy period for one woman may be normal for another.

However, for any individual woman, the amount of blood lost every month tends to remain relatively constant, apart from slight variations with age. It would be unusual for a woman to lose a few teaspoonfuls of blood one month and a pint of blood the next. Because the amount of blood loss is relatively constant, each individual woman tends to consider her own periods to be normal for her, and usually only worries about them or consults her doctor when she feels that her periods have changed.

Doctors define menstrual bleeding as heavy (and call it menorrhagia) when periods last longer than seven days or more than 80ml of blood is lost during a period. It is possible to measure menstrual blood loss and doctors can have this done by their local hospital departments, especially if there is concern about a woman becoming anaemic. However, the way that a woman perceives the heaviness of her period is as important as any clinical measurements.

Clots

When menstrual bleeding is heavy, clotting can also occur. Losing large clots can be extremely upsetting and even painful if they are large because they can cause cramping as they pass through the cervix. There is a simple explanation as to why these large clots are formed. All blood contains a clotting factor. To enable menstrual blood to flow freely from the uterus (womb) and leave your body without clotting, the uterus produces an anti-clotting agent. But if the menstrual loss is heavy, it is possible that the anti-clotting agent will be used up before a period has finished, so that the remaining blood is likely to form clots.

What causes heavy bleeding?

If your periods have changed, it's very important to see your doctor. There are a number of diseases which can cause heavy bleeding (see list below). The doctor will investigate possible causes and offer the appropriate treatment. But in about half the women with heavy bleeding, no cause can be found.

Some causes of heavy menstrual bleeding

When menstrual bleeding is heavy, clotting can also occur. Losing large clots can be extremely upsetting and even painful if they are large because they can cause cramping as they pass through the cervix. There is a simple explanation as to why these large clots are formed. All blood contains a clotting factor. To enable menstrual blood to flow freely from the uterus (womb) and leave your body without clotting, the uterus produces an anti-clotting agent. But if the menstrual loss is heavy, it is possible that the anti-clotting agent will be used up before a period has finished, so that the remaining blood is likely to form clots.

1. Unexplained - for half of all cases no cause can be found.
2. Contraceptive coil (IUD) - the coil can cause heavier, longer periods.
3. Injectable contraception (Depo Provera) - can cause heavy or prolonged bleeding.
4. Pelvic disorders:

• Fibroids - these benign (not cancerous) growths in the muscular wall of the uterus are a common cause of heavy bleeding.
• Polyps - these benign growths of the lining of the uterus may cause heavy bleeding but more commonly lead to spotting between or after periods.
• Pelvic inflammatory disease - an infection in the reproductive tract which can cause infertility and chronic pain if untreated.
• Endometriosis - a painful condition in which the lining of the uterus grows outside the uterus.
• Endometrial hyperplasia - thickening of the lining of the uterus, leading to heavier bleeding.
• Endometrial cancer - cancer of the lining of the uterus, causing heavy periods, bleeding between periods and blood-stained vaginal discharge. Rare, but more common in women after the menopause.

1. Blood and hormonal conditions:

• Hormone imbalances - can stop ovulation (egg release) leading to build-up of endometrium and heavier periods.
• Hypothyroidism - an underactive thyroid gland can cause heavier periods.
• Blood clotting disorders.
• Use of anticoagulant drugs.

The menstrual cycle is affected by stress. If you are going through any kind of life crisis, it is possible that your periods may settle down once that crisis has been resolved. Meanwhile reassurance from your doctor that there is nothing seriously wrong may help you to accept this change as a common and usually temporary response to stress. For many women, however, there is no easy solution to the stress in their lives. If this is the case, you will need to decide whether you want treatment for your heavy bleeding.

In all cases, the first step to take is to visit your GP and explain that your periods have changed. Once your doctor and/or gynaecologist have carried out the preliminary tests described in the next section, and you have been given the medical all clear, what happens next will largely depend on how you feel about your heavy bleeding.