An ob-gyn weighs in on how heavy menstrual bleeding affects your ability to conceive.

Woman with bad cramps

What causes heavy menstrual flow? For 2 weeks, this heavy period can impose painful side effects such as cramps, fatigue or disturbed sleep. Some also have to cope with added anxiety as they suffer heavy, painful and prolonged menstrual bleeding.

Dr Beh Suan Tiong, an obstetrician and gynaecologist at Thomson Medical, has details on this complex condition, as well as its effects on fertility.  

The average woman loses about 40ml of blood at every menstrual cycle. Those with HMB lose about twice that, that is, 80ml and sometimes more.”

What are the symptoms of heavy menstrual bleeding (HMB)?

The average woman loses about 40ml of blood at every menstrual cycle. Those with HMB lose about twice that, that is, 80ml and sometimes more. However, there is no practical way to measure the exact volume of blood a woman loses ― the most practical way of diagnosing HMB is by its symptoms, which include:

1. Soaking through one or more sanitary pads or tampons every hour for several hours consecutively.

2. Needing to wake up to change sanitary pads or tampons during the night.

3. Bleeding that lasts more than a week.

4. Passing large blood clots.

5. Having to reschedule social activities and/or take days off work or school because of bleeding.

6. Severe cramping which may lead to the overuse of painkillers during the menstrual cycle.

7. Anaemia and symptoms of anaemia such as fatigue, shortness of breath and headaches.

You should see a gynaecologist when you have any of the above symptoms.

How serious can heavy menstrual bleeding get?

HMB can be mild or very severe. Some women with HMB may experience abnormally heavy bleeding exceeding a week but experience no pain or cramping. Others may experience extreme cramping and excessive bleeding that they become anaemic and need emergency blood transfusions.

Any stats on the number of women who suffer from this condition?

A recent online survey of 1,031 women of child-bearing age (from under 18 to above 40) shows that one in three women might have HMB.

This is somewhat reflected in my practice ― about 20 to 30 per cent of the women I see have HMB. It is very difficult to give an exact figure because HMB is under-reported with many women suffering for years before seeking medical help.

Some women with HMB see me to treat other conditions such as pain during menses and/or sex, irregular menses and difficulty conceiving. When I dig deeper, I learn that they also experience HMB.


Woman talking to doctor

What causes HMB and does it indicate other health conditions?

By far the most common causes of HMB in older women are hormonal imbalances, fibroids and polyps, but it can also be caused by many other different conditions.

Gynaecologists use a FIGO (The International Federation of Gynaecology and Obstetrics) classification system called PALM-COEIN to define the potential causes of HMB. It stands for:

* Polyp (Uterine) An abnormal growth of tissue projecting from the mucous membrane of the uterus.

* Adenomyosis A condition in which the inner lining of the uterus (the endometrium) breaks through the muscle wall of the uterus (the myometrium).

* Leiomyoma (Uterine) Also known as fibroids, benign smooth muscle tumours that very rarely become cancerous.

* Malignancy and hyperplasia An abnormal increase in the number of cells in an organ or tissue. Before cancer or malignant cells form in the body’s tissues, the cells go through abnormal changes ― the first is called hyperplasia, when there is an increase in the number of cells but the cells themselves appear normal under a microscope.

* Coagulopathy A condition in which the blood's ability to coagulate (form clots) is impaired.

“Some but not all HMB appears to run in families – you are likely to experience HMB if your mother or female relative(s) have suffered/ have been suffering from HMB.”

* Ovulatory dysfunction When ovulation is abnormal, irregular or absent, which often leads to irregular or even absent menses.

* Endometrial A catch-all classification applied to HMB, IMB (intermenstrual bleeding) or prolonged bleeding not obviously caused by other identifiable abnormalities, in women of reproductive age who seem to have normal ovulatory function. In cases of HMB, one possible cause could be a primary disorder of mechanisms regulating local endometrial haemostasis (the process by which bleeding is stopped by vasoconstrictors such as endothelin-1 and prostaglandin).

* Iatrogenic An illness or effect caused by a procedure or medication such as the side effect of a drug. HMB is a relatively common consequence of the use of anticoagulant drugs such as warfarin, heparin and low molecular weight heparin.

* Not yet classified This category includes several known uterine entities which might contribute to or cause HMB but which have yet to be adequately researched or defined... As further evidence becomes available, these entities may be placed into an existing categories in the system or allocated new categories.

Is this condition hereditary?

Some but not all HMB appears to run in families ― you are likely to experience HMB if your mother or female relative(s) have suffered/have been suffering from HMB. This is particularly so if the HMB is caused by fibroids and polyps; conditions which also seem to run in families.

Can HMB affect a woman’s fertility?

It all depends on what causes the patient’s HMB. If it is caused by adenomyosis, or fibroids or polyps growing within the endometrial cavity, the patient is likely to suffer from subfertility as well.

Women with adenomyosis and endometriosis may also experience pain during intercourse and are more likely to be put having sex off. Severe anaemia could also restrict the growth of the foetus, causing it to be too small.

It is important that all women (especially above the age of 40) who have had prolonged heavy menstruation undergo sampling of the womb lining to ensure that there are no serious underlying medical issues like hyperplasia or cancer. Left untreated, endometrial hyperplasia may progress to endometrial cancer.

Will treating this condition improve the woman’s fertility?

Several conditions can cause HMB ― a physician’s choice of first-line treatment will depend on the underlying cause and how far it has progressed.

Often, by the time women present with fibroids or endometriosis[JGHL1] , some kind of surgery is required. However, if caught early, medication can manage both fibroids and endometriosis.

Hormonal causes (HMB in the absence of an organic pathology such as fibroids or endometriosis etc.) typically respond well to oral contraceptives or hormone-releasing IUS.  Other options like nonsteroidal anti-inflammatory drugs (NSAIDs) or antifibrinolytics medication like tranexamic acid, which are not hormonal medications, may also be considered.

In women with HMB because of hormonal issues, the hormones released by the IUS reduce HMB symptoms and the symptoms of conditions that may contribute to HMB. It is an excellent alternative to unnecessary surgery (hysterectomy-womb removal). It can also alleviate pain in women with endometriosis, and takes away the need for them to be on prolonged oral contraceptives. Another advantage is that this one off-treatment can last about five years, which makes it very convenient.

Photos: iStock

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