Gynaecology: Clinics |
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Menorrhagia clinic (Clinic for heavy periods)
Menorrhagia (Heavy periods), is a common cause of discomfort among women of childbearing age in the UK. The loss of substantial menstrual blood loss interferes with physical, emotional, social, and material quality of life. It is estimated that around one in 18 women experience periods heavy enough to need treatment.
The typical woman’s period lasts for around 5 days, during which time she may lose around 10-40 ml (up to 2 tablespoons) of blood. Heavy periods are characterised by periods that lasts longer than 7 days or passing large clots of blood during your period. This usually represents at least 60ml blood and this is enough to make some women anaemic.
The clinic has every modern test and treatment to help women with heavy periods. Facilities in the clinic include specialist gynaecologist consult, examination, ultrasound, biopsies, removal of old IUDs, iron therapy, therapy to improve the wombs clotting system, non hormonal therapy options, insertion of therapies under the skin to into the womb, removal polyps and ablation of fibroids.
Hospital treatments include examinations of the uterus under anaesthetic, removal of the lining of the womb, removal of the part of the womb responsible for bleeding, removal fibroids, day case removal of ovaries and vaginal or laparoscopic subtotal hysterectomy. However, the current political situation is that the commissioning health authorities may not fund some hysterectomies for menorrhagia on the NHS.
Heavy periods are common. Doctors often use the word 'menorrhagia' to describe unusually heavy periods and this is characterised by a flow that is a burden or that contains clots.
Cause of Heavy Periods
Although heavy periods are common they are rarely due to serious disease. Anything that makes the womb large will leave a bigger area to bleed from and this is associated with a heavy loss. Fibroids are simple harmless lumps of gristle in the womb but they can make the uterus larger and increase menstrual loss. A condition known as “adenomyosis” occurs when glands get blocked in the uterus. This can also cause the uterus to enlarge and cause uncomfortably heavy periods. Bleeding from the uterus is under the influence of hormones. It is therefore easy to understand that any abnormality of the female hormones or the way that the uterus responds to them will also be associated with heavy periods. Inflammation of the uterus also causes heavy periods. The uterus can be inflamed due to a previous infection or an irritant device put in the uterus (such as a contraceptive coil).
Investigations required for heavy periods
The essential test for someone with heavy periods is a blood count. This checks the haemoglobin levels and makes sure that the iron levels are being maintained. If you lose more blood than you can make then your blood count can drop and you can become anaemic. It is also worth having an examination to see what size the uterus is and make sure there is no gynaecological abnormality. If there was any doubt your doctor will arrange an ultrasound scan. This is not necessary if a pelvic examination is easy, tolerable and the uterus is normal. If there are other symptoms then it is often worth checking hormones but this is not routinely needed.
It is sometimes useful to know how heavy your periods are. There are two ways of doing this. One is to collect your sanitary pads over a monthly cycle and send them to the laboratory where the loss can be measured. The inconvenience associated with this technique is obvious. An alternative is to use a picture chart method which is on the reverse of this sheet.
Treatment
Treatment depends on your age and how much trouble the periods cause. For example if you are 51 (the average age of the menopause) then it is worth considering simple treatments in the hope that the menopause will bring a natural cure soon. However if your periods are heavy and intolerable and you are only 30, we have to consider that you probably have another 20 years of menstruation ahead of you.
It is important to appreciate that heavy periods are not a disease and therefore the treatment is designed to make life more comfortable for you. This means you have to decide in your own mind whether any potential inconvenience associated with treatment is worth the relief it brings. The main purpose of this leaflet is to introduce all the various therapies to help you decide what is right for you.
Treatment is best divided into:
- Alternative medicine
- Simple therapy during periods
- Hormonal medicine
- Surgery
There is no evidence that homeopathy, acupuncture or herbal medicine make any difference to the condition. Homeopathy and acupuncture are safe and many people try them. Herbal medicines are promoted for many unremitting conditions. Provided unrealistic exceptions are not raised, little harm is likely to result from trying one of the variety of preparations. Techniques relying on the elimination of mythical toxins from the body are also popular. Menstrual loss varies naturally and it is tempting to attribute a good period to alternative medicine but this has no scientific merit. However, Medicine is not omnipotent, does not have all the answers, and dietary changes do work for a limited number of conditions and it does little harm to try.
Treatment during periods
There are therapies that only need to be taken during menstruation. They are most effective when the bleeding is heaviest. There are two types of simple medication that can reduce menstrual loss. One reduces clots and the other effects bleeding.
Reducing clots
One medicine effects the way that the natural chemicals in the womb cause the blood clots to dissolve. It works by making the coagulation system more efficient. There are several agents available. The most popular is known as Tranexamate (Cyklokapron). We would normally recommend taking one tablet (500 mg) four times a day during the heavy flow. Ethamsylate (Dicynene) is probably just as effective. It is not thought to be associated with many side effects but it can cause some nausea and on occasions may cause diarrhoea. These side effects are unusual but they are always transient and stop when you stop taking the drugs. Trials show that this simple and very safe therapy can reduce the blood loss of the average woman by 50%. This does not mean to say that your loss will be reduced by 50%. Some women have a greater loss reduction than this but it is less effective in others. However it is simple and worth trying.
Reducing bleeding
Another medicine which reduces menstrual blood loss is a group of drugs known as Prostaglandin synthatase inhibitors. This is just a long fancy name for a modern Aspirin tablet (anti inflammatory agent). For some reason Aspirin does not seem to be very good for reducing menstrual loss but all of its modern equivalents e.g. Mefenamic acid, Ponstan, Brufen and Naproxen etc seem to work. Trials show that if taken during heavy periods they reduce menstrual loss by about 30%. They work by inhibiting an enzyme which causes small blood vessels to leak. The side effects are the same associated with taking an Aspirin. These are available without prescription and again it is worth trying.
Hormone treatments
Hormone treatment includes:
- the contraceptive pill
- progesterone
- androgens
- agents that block hormones
The contraceptive pill
The contraceptive pill is the favourite hormone preparation prescribed by Doctors. Despite sensational reports by the media, it has been one of the most researched and intensely studied hormone ever invented by the pharmaceutical industry. We know it reduces the risk of cancer (ovary and uterine but no obvious effect on breast) and there is no doubt that it protects women from other diseases such as pelvic inflammatory disease and endometriosis. However you can only get it on prescription as there are some women who should not take it e.g. women with previous thrombosis or pre-disposition to thrombosis. There are many reasons why women do not want to take the contraceptive pill and it does not agree with many others. However it can be used to treat heavy periods with good effect in some cases and can half the average loss. Stories that women over the age of 45 should not take the pill or that long term use is dangerous have been discredited.
Progesterone
Progesterone is the hormone of pregnancy. It is produced naturally by the afterbirth as a messenger to tell the uterus (womb) not to have a period. If taken in high doses it will mimic a pregnancy and therefore stop menstruation. Its treatment is safe (nature does it for nine months at a time). However in high doses it can cause the same side effects as pregnancy. This means that some women feel nauseous to begin with and can get bloated. Bloatedness is water retention and not fat and can be treated with water tablets. However it can be uncomfortable. One way to get round the side effects is to give a much lower dose of progesterone. One very effective treatment is to give the mini pill (progesterone only pill). This also reduces menstrual loss but can make menstruation unpredictable. Sometimes the unpredictability is worse than the heavy flow but it is an option that is at least worth considering.
The way to get rid of the side effects of progesterone is to put a progesterone pellet into the uterus. This means that only the uterus is influenced by the hormone and this helps get round the problem of side effects. Unfortunately the dose of the pellet we put into the uterus is very low and therefore menstruation can be unpredictable to begin with. It takes about three months to settle down but most women will report that their loss is reduced by about 70%-90%. This is a significant reduction. However the disadvantage of this technique is that it is uncomfortable having the pellet put in the uterus. It is the same as having a coil fitted. If the treatment does not work, the pellet can easily be withdrawn.
Androgen treatment
There are hormones available that are androgens (male hormones). These are also effective at reducing menstrual loss. In low doses, the bleeding is substantially reduced and in high doses the bleeding stops altogether. However the side effects are those of the male hormone and they will cause weight gain (fat, not water like progesterone) and in high doses they can cause depression, make the skin greasy and can cause hair growth. For these reasons it is not an option that many women choose.
Medicines that mimic the menopause
There are medicines that block the natural female hormones. The disadvantage of this is that the body then acts as if it is in the menopause. The advantage is that the menstrual cycle stops but the disadvantages are night sweats and hot flushes. You feel as if you are in the menopause. For this reason most women decline this type of therapy.
Surgery
There are two surgical options. One is to remove the lining of the uterus (endometrial surgery) and the other is to remove the uterus (hysterectomy). A D&C has no long term effect on menstrual loss. It can occasionally be a useful diagnostic test but it is not a treatment.
Endometrial Surgery
There is a useful option for women whose main symptom is a heavy flow. The surgeon removes the lining of the inside of the womb. This only removes the area that bleeds. An analogy might be cauterising blood vessels for people who have heavy nose bleeds. Most women prefer to have an anaesthetic.
There are many different ways of removing the lining of the womb. It can be lasered, coagulated, cauterised, excised or literally cooked. About one in three women will have no more periods after this technique and the rest will find that their loss is reduced by 90% (only 10% of what it was before). It can also help pain in about half of the cases. However in about 10% of women with painful heavy periods the pain can actually be worse after this procedure. Generally speaking about 10% of women are unsatisfied with an endometrial resection and still request a hysterectomy afterwards. However on a more optimistic note 90% of women are satisfied with it. The great advantage of this to a hysterectomy is that the surgery is minor, you don’t need to stay in hospital overnight (you can actually have it done in the outpatients clinic although I would not recommend this). Most women require a couple of weeks to recover from the anaesthetic and therefore should have two weeks off work. It is also associated with a discharge that can last for about a month.
The major disadvantage of the technique is that it is no good for women who want to keep their fertility. Because it removes the lining of the uterus it then makes it difficult to get pregnant afterwards. The whole purpose of having a period is to shed the uterine lining so that every month a potential egg has somewhere to develop. If this lining is removed then there is nowhere for the egg to develop. As a general rule the operation should only be considered by women whose family is complete and it is worth considering a sterilisation operation at the same time. Obviously if your partner has had a vasectomy this does not apply.
Hysterectomy
A hysterectomy is a very common operation and is chosen in about 20% of the population of the United Kingdom. The number of women who chose a hysterectomy does vary. For example, only 50% of women in California will take their uterus to the grave whereas there will be very few Arab or African women who will want to lose their periods. Removing the uterus only removes the organ associated with pregnancy and does not effect hormones. Women who have had a hysterectomy don’t have any more periods. This also means they can’t have any more children. The decision to have a hysterectomy should not be taken lightly. It usually requires 2 days in hospital. Many women are back at work after 2 months but it can take 3 months to recover completely.
More information
This page is intended to provide you with information and to give you some background to ask further questions. You might like to experiment with different medical options. However if a surgical solution is applicable to you there are other information leaflets which cover these options in more detail and there are books available from most book stalls.