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Heavy Menstrual Bleeding (HMB) and other menstrual problems

By Dr J Kabyemela, MD

The commonest problems that any gynaecologist will have to deal with in his/her career will be to do with menstruation. Menstrual problems range from unexplained absent periods (amenorrhoea) through irregular periods, frequent periods, erratic infrequent periods to heavy and or prolonged periods. Squeezed somewhere in between is the problem of inter-menstrual bleeding.  Not infrequently, a woman will have a combination of any number of the described menstrual problems. There is no uniform explanation for menstrual problems and a proper work-up to identify the underlying cause is necessary in order to offer the appropriate solution.

Heavy Menstrual Bleeding (Menorrhagia)

The commonest menstrual problem is heavy periods or excessive menstrual loss. The old medical term for Heavy Menstrual Bleeding (HMB) that remains cyclical is menorrhagia.

Heavy Menstrual Bleeding (HMB) affects roughly 1 in 5 women of child-bearing age. In fact, some studies put the figure at around 1 in 3 (30%). It is therefore quite common. Prevalence in any society is heavily influenced by the use of hormonal contraception such as the combined pill, injectable contraceptives (Depo-Provera) and the Mirena intrauterine contraceptive device. These contraceptive measures tend to have a major influence on menstruation with the pill producing regular, usually normal or light ‘periods’ and the other mentioned contraceptive methods tend to stop periods altogether during the duration of use. In some societies, availability and uptake of any form of hormonal contraception is patchy at best and here, the problem of heavy periods would be expected to be comparatively more prevalent.

Many women take heavy periods as something that happens, that cannot be influenced and where one has simply got to get on with it. That is, of course, not the case. Heavy periods are a common problem but one that is relatively easy to manage effectively. There are many options and we will come to these in this chapter in due course.

Causes and risk factors for HMB

In many cases of heavy periods, no obvious underlying cause can be identified. However, for some patients there are identifiable risk factors, the management of which can help alleviate the problem.

Age: Heavy periods affect women of all ages, from the early teens soon after menarche to women in the peri-menopause, in their late 40s and early 50s. However, it is the case that this problem is more prevalent in the later years, typically from the mid-30s onwards. When a woman starts experiencing heavy periods at that time of her life, the problem tends to get worse with passing time. Spontaneous resolution is rare. A medical intervention is often necessary.  Age is very important because it does heavily influence the choice of treatment options.

Blood disorders: Studies show that anything up to a quarter of women with severe menorrhagia will have an underlying blood disorder. The commonest is a condition called von Willebrand’s disease (vWD). This is a condition where there is a deficiency of a blood protein called von Willebrand factor. This protein is essential for effective blood clotting and its deficiency means the person is prone to excessive bleeding. People with this condition may otherwise present with frequent unprovoked nosebleeds and/or easy bruising. In other cases, heavy menstrual loss is the only clinical feature. A blood test will usually clinch the diagnosis. The name comes from the Finnish doctor who first described the condition in the early 20th century. Because this condition is not rare, it is important for a doctor to try to rule it out in a woman presenting with heavy periods especially in the absence of any other possible underlying cause. Haemophilia is a condition where clotting Factor VIII (Haemophilia A) or Factor IX (Haemophilia B) is deficient. Haemophiliacs will therefore have bleeding tendencies and, for a woman sufferer, heavy periods will be a prominent feature of the condition. However, because of the nature of its inheritance, haemophilia is overwhelmingly a male condition. Women sufferers are quite uncommon.

Fibroids: Fibroids or uterine myomas as they are medically known are very common benign tumours, usually presenting in women in their 30s onwards. However, they can be seen in women who are much younger than that. Fibroids tend to grow slowly over several years but, occasionally, fairly rapid growth has been observed in some women. In most cases, fibroids do not cause any problems at all and most women would remain oblivious of their presence until discovered incidentally during routine imaging investigations for other reasons such as pregnancy. An ultrasound scan of the pelvis will easily identify a fibroid, its exact location in the uterus and its size. Fibroids can be found jutting into the uterine cavity. These are known as sub-mucosal fibroids. They can also grow within the wall of the uterus. Those are called intra-mural. The third type is sub-serosal and those are the fibroids that grow on the outer wall of the uterus projecting into the pelvic or abdominal cavity. Some women will have several, encompassing all three types. Location of the fibroid is important. Fibroids that project into the uterine cavity could cause or worsen heavy periods. Likewise, large or multiple intra-mural fibroids have been associated with heavy periods. However, fibroids that grow from the outer wall of the uterus, projecting outwards, are not usually associated with heavy periods. It is important therefore to be careful not to rush to a judgement of identifying the cause of a woman’s menorrhagia on seeing a fibroid on a pelvic scan. Quite often it is not to blame.

Treatment options: Next Page

Intramural fibroids

Submucosal fibroids