Heavy Menstruation

For tens of millions of women around the world, menstruation regularly, and often catastrophically, disrupts their physical, mental, and social wellbeing(1). A normal menstrual cycle has a frequency of 24–38 days, lasts 7–9 days, and results in 5–80 mL of blood loss. However, variations in any of these 4 parameters constitute abnormal uterine bleeding(2), which includes conditions such as amenorrhea (absence of menstruation)(3), dysmenorrhea (pain during the menstrual cycle)(4), and menorrhagia (abnormally heavy or prolonged menstrual periods)(5). Slowly, since the publication of guidelines updated by the International Federation of Obstetrics and Gynaecology (FIGO) in 2018, this older, more intimidating, terminology such as ‘menorrhagia’, is being replaced in favour of more approachable terms that describe the nature of the condition, such as ‘heavy menstrual bleeding’(2).

Approximately 25% of women experience menstrual disorders(2,6–8), but, depending on the population studied, this number can rise to as much as 60%(2,9), and there is speculation if this represents the true prevalence as often women do not seek help for their symptoms and even when they do, the diagnostic procedure combines both subjective and objective components(2). Personally, I do not find this hard to believe, because, until I began writing this blog, I did not realise my experiences as a teenager were more than something I just had to deal with every month.

My story

Rewind to my early teens and I felt exhausted all the time. I did not want to make too much of a fuss, but my parents eventually convinced me to go to the doctors and I was diagnosed with anaemia and prescribed iron tablets. A few years later, I returned to the doctors for a check-up, and it was revealed that I was no longer anaemic – I thought it strange that my anaemia had just upped and left, but I was happy to leave the iron tablets, and their associated side effects, behind. You may be thinking why is she telling me this? Well, throughout this timeframe, I had also begun experimenting with different contraceptive methods because a friend of mine, who had gotten the implant, had completely stopped her monthly bleed. For me, a shy teen who began to dread their time of the month, and plan all social events, especially sleepovers, around their cycle to avoid embarrassment, this seemed like something I could only dream of. Until recently, I did not think these 2 experiences were related, because throughout the whole process of being diagnosed with, and then magically recovering from anaemia, I was not once asked about my cycle. Now, having spent the time researching for this blog, it has become clear that my decision to begin hormonal contraceptives was in fact the cause of my miraculous recovery from anaemia.

I do not think my experience is unique, and it only serves to highlight a need for further education and de‑stigmatisation of conversations about periods. Looking back now, I wonder why I never questioned my cycle before, or raised the conversation with a doctor, but one look at the National Health Service (NHS) website makes it clear why. When you access the NHS website and search for menstrual conditions, it gives you a list of conditions with each page following a similar structure which goes a bit like this: ‘Title’ (e.g., heavy periods) followed by a short paragraph on what this means, normally starting with a sentence such as “some women naturally have heavier periods than others”. I imagine this is intended to put the reader at ease and stop every person who menstruates panic at the first symptom. However, if I think back to myself at 13, with very little knowledge of what is deemed ‘normal’, I know that I would think “everyone goes through this, I am just being dramatic – stop worrying!”. Therefore, there is a clear need for not only medical professionals to be aware of these conditions and prepare to ask the appropriate questions at the correct times (such as alongside an anaemia diagnosis), but also for anyone who menstruates to understand when to seek medical help, preferably before their first menses. Whilst I was at school, I do not remember much in the curriculum about menstruation other than the basics. The current guidance for schools states that “pupils should be taught key facts about the menstrual cycle including what is an average period, range of menstrual products and the implications for emotional and physical health”(10). There is no specific content which accompanies this, allowing individual schools to create their own curriculum. Therefore, I think that some direct guidance on what is “normal” should be included, empowering people to seek medical attention when necessary. So, for those of us who were not taught about menstrual conditions at school, let’s make a start in understanding just one of these conditions – heavy menstrual bleeding.

Heavy menstrual bleeding – a brief education

Heavy menstrual bleeding is a common cause of anaemia and reduced quality of life in adolescents(5), and is characterised by(11):

  • A flow which requires changing of sanitary products every 1 to 2 hours
  • Use of multiple sanitary products together
  • Menstruation which lasts longer than 7 days in duration
  • Blood clots which are larger than 2.5 cm
  • Bleeding through clothes or bedding

Additionally, patients may avoid daily activities, and experience tiredness and shortness of breath(11). There are many causes of heavy menstrual bleeding, including polycystic ovary syndrome, endometriosis, stress, and depression, to name a few(11). However, the most common cause in adolescents is ovulatory dysfunction, followed by coagulopathies(5).

Diagnosis for all abnormal uterine bleeding disorders, including heavy menstrual bleeding, includes(12):

  • Taking a detailed medical history
  • A pelvic examination
  • Laboratory tests, including pregnancy tests and complete blood count
  • Endometrial sampling for patients over 45 years and in younger patients with a history of significant oestrogen exposure
  • Transvaginal ultrasonography, if a structural aetiology is suspected, or if symptoms persist despite treatment

What are the treatment options?

Treatment should focus on improving quality of life and should not have the sole goal of reducing blood loss. Currently, haemostatic medications and/or hormonal agents are available depending on the aetiology(13). The 52 mg levonorgestrel intrauterine device (IUD) has shown superior efficacy in heavy menstrual bleeding, where this is the primary symptom, yet, this is an off-label use for some IUDs. In patients where an IUD is not appropriate, other hormonal methods, such as combined or progestogen-only contraceptive pills may be prescribed. Currently, there is a lack of data on efficacy from randomised controlled trials(2), indicating a need for further research, especially to determine whether progestogen-only contraceptives and their lower associated contraindications, provide greater efficacy than their combined counterparts(13). Surgical approaches are also an option, with endometrial ablation effectively controlling bleeding 4 months post-surgery. However, at 5 years, efficacy is similar to medical management(2), therefore, medical management remains the preferred choice where possible to avoid surgical risks and preserve fertility(12). Tranexamic acid, and non-steroidal anti‑inflammatory drugs (NSAIDs), are further medical interventions available and have been shown to reduce blood loss by up to 50%(13), which shows some promise for patients trying to conceive. Finally, in severe cases, where bleeding causes haemodynamic instability, emergency interventions such as uterine tamponade, intravenous oestrogen, dilation and curettage and uterine artery embolization may be required(12).

Unfortunately, there is currently no consensus on the best diagnostic and treatment strategies, and pharmacological treatment is often initiated without further investigation, therefore, further studies on the most effective treatments are required(13). Additionally, although abnormal uterine bleeding is higher in adolescents, compared to adults, most current recommendations are not specific for this age, hence, further studies in this age group are also required(14). Current evidence also suggests that there is poor satisfaction with standard treatment options, resulting in women opting for major surgeries such as hysterectomies, when they would benefit from a tailored approach both in diagnosis and treatment, highlighting a further deficiency, and need for, biomarkers(15).

What does the future hold?

Luckily, there is growing awareness and support for research in this area with the Gynecologic Health and Disease Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development convening a 2-day meeting in 2018 titled, “Menstruation: Science and Society” with the aim to “identify gaps and opportunities in menstruation science and to raise awareness of the need for more research in this field(1). Additionally, the non‑governmental organisation (NGO) FIGO, founded in 1954, continues to support the health and wellbeing of women and newborns worldwide, and this year for International Women’s Day, focused on raising awareness of abnormal uterine bleeding, including heavy menstrual bleeding (https://www.figo.org/news/breakthebias-challenging-normalisation-menstrual-disorders)(16). This is promising, as treatment should not be stumbled upon as a result of conversations with friends (as it did for me) but should be diagnosed professionally and treatment tailored accordingly.

To achieve this, attitudes need to continue to change, as even I, when writing this, had moments of “is this really that important in the grand scheme of things?” But yes, it is. It has a huge impact on many people’s quality of life and therefore it should be given as much publicity and research as any other condition. Conversations about menstruation should not be shied away from, and general practitioners should become familiar with asking women about their menstrual cycle to begin investigations and initiate appropriate treatment where necessary. Until people become comfortable discussing menstruation and become aware of these conditions and their associated symptoms, many more women will suffer in silence.

References

  1. Critchley HOD, Babayev E, Bulun SE, Clark S, Garcia-Grau I, Gregersen PK, et al. Menstruation: science and society. Am J Obstet Gynecol. 2020 Nov;223(5):624–64.
  2. Davis E, Sparzak PB. Abnormal Uterine Bleeding. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 May 9]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK532913/
  3. Klein DA, Paradise SL, Reeder RM. Amenorrhea: A Systematic Approach to Diagnosis and Management. Am Fam Physician. 2019 Jul 1;100(1):39–48.
  4. Ferries-Rowe E, Corey E, Archer JS. Primary Dysmenorrhea: Diagnosis and Therapy. Obstet Gynecol. 2020 Nov;136(5):1047–58.
  5. Borzutzky C, Jaffray J. Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents. JAMA Pediatr. 2020 Feb 1;174(2):186–94.
  6. Ansong E, Arhin SK, Cai Y, Xu X, Wu X. Menstrual characteristics, disorders and associated risk factors among female international students in Zhejiang Province, China: a cross-sectional survey. BMC Women’s Health. 2019 Feb 18;19(1):35.
  7. Karout N, Hawai S, Altuwaijri S. Prevalence and pattern of menstrual disorders among Lebanese nursing students. Eastern Mediterranean Health Journal [Internet]. 2012 [cited 2022 May 9];18(4). Available from: http://www.emro.who.int/emhj-volume-18-2012/issue-4/article-07.html
  8. Kwak Y, Kim Y, Baek KA. Prevalence of irregular menstruation according to socioeconomic status: A population-based nationwide cross-sectional study. PLOS ONE. 2019 Mar 19;14(3):e0214071.
  9. Mariappen U, Chew KT, Zainuddin AA, Mahdy ZA, Ghani NAA, Grover S. Quality of life of adolescents with menstrual problems in Klang Valley, Malaysia: a school population-based cross-sectional study. BMJ Open. 2022 Jan 1;12(1):e051896.
  10. Relationships and sex education (RSE) and health education [Internet]. GOV.UK. [cited 2022 May 18]. Available from: https://www.gov.uk/government/publications/relationships-education-relationships-and-sex-education-rse-and-health-education
  11. NHS. Heavy periods [Internet]. nhs.uk. 2017 [cited 2022 May 13]. Available from: https://www.nhs.uk/conditions/heavy-periods/
  12. Wouk N, Helton M. Abnormal Uterine Bleeding in Premenopausal Women. Am Fam Physician. 2019 Apr 1;99(7):435–43.
  13. Overview | Heavy menstrual bleeding: assessment and management | Guidance | NICE [Internet]. NICE; [cited 2022 May 18]. Available from: https://www.nice.org.uk/guidance/ng88
  14. Ramalho I, Leite H, Águas F. Abnormal Uterine Bleeding in Adolescents: A Multidisciplinary Approach. Acta Med Port. 2021 Mar 31;34(4):291–7.
  15. Chodankar R, Critchley HOD. Biomarkers in abnormal uterine bleeding†. Biol Reprod. 2019 Dec 24;101(6):1155–66.
  16. #BreakTheBias: Challenging the normalisation of menstrual disorders [Internet]. Figo. [cited 2022 May 18]. Available from: https://www.figo.org/news/breakthebias-challenging-normalisation-menstrual-disorders
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