Most women have a menstrual cycle every 24-35 days. During this menstrual cycle, a woman loses approximately three tablespoons (35 -40 ml) of blood in a period ranging from four to seven days, but there are women who lose more than that amount. This may be due to losing a great deal of blood in a normal length period or the period lasting longer than normal. Menorrhagia, meaning heavy or prolonged periods, is said to occur when a woman loses more than five to six tablespoons (75-80 ml) of blood. This is concerning because it can lead to medical problems, such as anemia, and can be a sign of an abnormal mass in the uterus.

WHAT CAUSES THESE HEAVY OR PROLONGED MENSTRUAL PERIODS?

There are several causes of this issue, but the most common ones are: fibroids or polyps in the uterus, not ovulating on a monthly basis or a medical condition that causes increased bleeding. Less often, but a serious concern, is cancer of the uterus. Let’s talk about each one of these briefly. Fibroids or polyps in the uterus: These are primarily non-cancerous growths that occur in the inside layer of the uterus and, at times, within the muscle layer of the uterus. Not ovulating on a monthly basis, or “anovulation,” is also a common cause. This is when the ovaries do not produce an egg each month. This is relatively common in women who are approaching menopause, in adolescents and in women with what is called Polycystic Ovarian Syndrome (PCOS). Increased bleeding tendency is when women have a bleeding disorder or are taking certain medications that cause abnormal bleeding. Some examples of these include women with a low platelet count, because platelets help the blood to clot normally; genetic diseases and certain medications such as “blood thinners” (ex. aspirin, warfarin). At times, the inner layer of the uterus increases in size, called “endometrial hyperplasia.” This can lead to cancer. Obesity is the greatest risk factor for this.

HOW DO I KNOW THAT I HAVE HEAVY PERIODS?

This is one of the most common questions I receive in my daily practice. Some of the signs that you may be having heavy periods include bleeding for more than seven days, changing pads or tampons during the middle of the night, passing clots greater than 1 inch wide, soaking a tampon or a pad every one to two hours on the “heavy” days of the period, having to use a tampon and a pad because of too much bleeding or feeling weak after each period due to blood loss. If you have any of these signs or symptoms, please call your gynecologist for further evaluation of this problem.

Arriving at the cause of heavy or prolonged menstrual periods involves a visit to your gynecologist. It is necessary to undergo a general physical exam including a pelvic exam. By doing the pelvic exam, your gynecologist may determine the presence of masses or irregularities in your uterus or ovaries that may explain these abnormal periods. Other tests may be necessary, and these may include a pelvic ultrasound, blood tests to determine the presence of anemia, hormone problems or genetic diseases. When the answer is not clear, minimally invasive methods may be necessary and these include looking inside the uterus with a hysteroscope (high-definition camera) or a biopsy of the inside of the uterus. Both of these can be done in the office.

HOW DO WE TREAT HEAVY OR PROLONGED PERIODS?

This depends on the cause. For example, as one of the most common causes of heavy or prolonged menstrual bleeding is a hormonal imbalance, it’s not unusual for your gynecologist to try hormonal birth control methods as the first measure. These methods include the pill, intrauterine devices (IUD), vaginal ring, monthly hormonal injections, implants under the skin, etc. These methods are generally effective in regulating the menstrual periods as well as reducing the monthly pains and cramps associated with them. For women whose heavy or prolonged periods are caused by benign growths in the uterus, there are several treatment alternatives. If the mass is in the inside of the uterus, such as a small polyp or fibroid, it can be removed without any incision with the use of the camera passed through the vagina. For larger benign masses, one option is an embolization of the uterine artery (cutting the blood supply to that part of the uterus. Some cases can only be treated surgically with a hysterectomy (surgical removal of the uterus) or of the large mass.

Surgical techniques have evolved through the years. Whereas it was customary to remove large fibroids and conduct hysterectomies by making a large incision in the abdomen, today many gynecologic surgeons are performing these surgeries with a robot. This approach allows us to see much more clearly and with higher magnification. For the patient, the recovery period is much shorter and the incidences of infection and complications are much lower than with previous methods.

For patients who have heavy bleeding not due to masses, a 90-second “ablation” procedure is available. This procedure is able to destroy the lining inside the uterus that would potentially be bleeding over the next 2 years of menstrual cycles. I offer this procedure in my office, without the need to go to a surgical center. It is a great option for patients who bleed heavily due to hormonal imbalances but do not want to get on hormones or have major surgery, and are done with child bearing.

Which treatment is the most adequate one for you will depend on the cause, your expectations with regards to future pregnancies and the recommendations given by your gynecologist. It is important to know that each of these treatment modalities have their benefits but also carry their inherent risks; therefore, it’s crucial that you have a discussion with your gynecologist in order to determine the best course of action for you.

Talk to your doctor if you are having heavy periods. Prevention is the key to good health. Stay healthy.