Heavy menses is a distressing condition that affects one in 20 women of reproductive age. Menstrual blood loss that is more than half a teacupful (80 ml) instead of the normal six to eight teaspoonfuls (30 to 40 ml) is considered heavy.

A widely accepted medical definition is excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life.

How will you know if you have heavy menses?

If you have heavy menses, you may typically experience one or more of the following symptoms:

* You feel tired, dizzy or unwell during and/or after menses.
* You pass large blood clots.
* Your menses soaks through clothes or bedding.
* You need to use double sanitary protection such as tampons and towels.

Sometimes, heavy menses can occur with other symptoms such as pain.

“If you have heavy menses, you may typically feel tired, dizzy or unwell during and/or after menses and pass large blood clots.”

What causes heavy menses?

The reasons for this menstrual condition can be grouped broadly into structural (imaging) and non-structural causes. These include:

* Small fleshy lumps or polyps.
* Adenomyosis.
* Leiomyoma, commonly known as a fibroid.
* Malignancy and/or hyperplasia, such as uterine and cervical cancer.
* A clotting disorder.
* Ovulation dysfunction, such as polycystic ovary syndrome.
* Endometrial dysfunction.
* Iatrogenic such as that caused by medication, for example, warfarin or a traditional copper coil.
* Infection, such as chlamydia.

Very often, when no specific causes for heavy menses are found after investigation, these cases are often called dysfunctional uterine bleeding (DUB).

How will your doctor diagnose this condition?

Your doctor will ask about your condition, medical and family history, as well as the medication you take regularly. He/She may also perform the following examination:

* A transvaginal ultrasound scan to detect structural abnormality of the womb and ovaries.
* Internal (vaginal) examination to look for vaginal and cervical abnormality.
* A Pap smear to screen for cervical cancer.
* Vaginal swabs to detect vaginal infection.

For women who are not suitable for internal scan or examination, their doctor may perform a more limited transabdominal scan and/or Magnetic Resonance Imaging (MRI) scan.

After conducting the above-mentioned assessments, your doctor will typically order the following blood tests:

* A full blood count to assess if you have anaemia.
* A thyroid function test as thyroid disease can affect menses.
* A coagulation screen if your menses was heavy since you were a teenager.

Ovarian tumour markers may also be requested if there is a suspicious ovarian cyst. 

You won’t need any treatment if the condition does not interfere with your normal life. However, treatment will be recommended if anaemia or a serious cause for the heavy menses is found.

For women with suspected submucosal fibroids, polyps or endometrial disease, your doctor will also recommend a hysteroscopy^ with endometrial biopsy to detect cancer and abnormalities of the womb lining. He/She may also ask you to keep a menstrual diary to assess and understand your condition, as well as to monitor the result of any treatment.

What are your treatment options?

For women who plan to conceive, they can take non-hormonal medication such as tranexamic acid and non-steroidal anti-inflammatory drugs (NSAIDs) alone or together to manage the heavy bleeding during menses.

Women who do not want to conceive, or where non-hormonal medications are not effective, the following hormonal methods are recommended if suitable. These methods can reduce blood loss and period pain, and some may even offer contraceptive benefits.

* Levonorgestrel-releasing intrauterine system (LNG-IUS): A plastic device inserted in the uterus that slowly releases the hormone to prevent pregnancy.
* Combined hormonal contraception: Combines oestrogen and a progestogen to prevent ovulation.
* Cyclical oral progestogens: Hormone tablets.
* Gonadotrophin-releasing hormone (GnRH) analogues: Brings forward menopause medically by several years for women in their late 40s, or to relieve severe symptoms before surgery.

“You won’t need any treatment if the condition does not interfere with your normal life. However, treatment will be recommended if anaemia or a serious cause for the heavy menses is found.”

If a woman with submucous fibroids or fibroids bigger than 3cm, your doctor may recommend the following procedures to remove the abnormal growth:

* A myomectomy using laparoscopic (keyhole) or traditional open surgery: Removing the fibroids through small incisions in the lower abdomen, or through a “bikini cut” respectively.
* Uterine artery embolisation: Shrinking the fibroid by blocking its blood supply.
* Ultrasound-guided high intensity transcutaneous focused ultrasound: A relatively new technique with limited evidence on its effectiveness and effect on fertility and future pregnancy.
* Ulipristal acetate oral medication: For women with moderate to severe fibroid symptoms but who are unable to have surgery.

Removing the womb’s lining is the definitive treatment for heavy menses. For women who have finished bearing their children, these surgical options include:

* Endometrial ablation ― This modern and safer method uses a balloon filled with hot fluid, or a netted device using radiofrequency to remove the lining of the womb. About half will stop bleeding while a further 40 per cent will have lighter menses.
* A hysterectomy ― Using keyhole or open surgery to remove the womb, its lining and the cervix. While this procedure stops your menses, this doesn’t mean that you are menopausal, since your ovaries will continue to produce female hormones.

A common but treatable condition, heavy menses not only impacts a woman’s life, it can also affect a couple’s relationship and their desire to conceive. Many causes of heavy menses can also affect fertility. Most have treatments that can improve fertility. Conversely, some treatments are not suitable for women who want to conceive.

An assessment by a gynaecologist is important to exclude cancer and manage the problem. The treatment options depend on what causes the heavy menses, the need for contraception or fertility, as well as the woman’s health and age.

^ A procedure that lets your doctor look inside your uterus in order to diagnose and treat causes of abnormal bleeding. 

Obstetrician and gynaecologist Dr Tan Toh Lick practises at Thomson Surgical Centre.

Photos: iStock

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