In the UK 5% of women are so troubled by heavy periods they seek medical help. Jane Bartlett looks at causes and treatments for menorrhagia

Are there times of the month when you wouldn’t dream of wearing white trousers? Heavy periods are a problem for a third of women who consider their menstrual flow excessive. For some, the blood loss is so bad they have to take a day off work with hourly trips to the loo to change sanitary towels or tampons. Getting out of the bath without a messy mishap is a challenge, and even a sanitary towel the size of a mattress doesn’t seem to be adequate overnight.

As well as being disabling, it?s alarming when you spot large clots of blood in your menstrual flow (menses) which is a common symptom of heavy blood loss ? known medically as menorrhagia. It can also lead to iron deficiency anaemia, so that you feel tired and run down, and may even experience palpitations and fainting.

How can you tell whether your periods are too heavy?

This is no easy matter. You can’t go to your next door neighbour and say, ‘Let’s compare periods’. Of course, doctors quantify things and define heavy menstrual loss as more than 80 ml per month, but measuring it is another matter entirely. Short of weighing tampons and towels before and after use, you have to decide if your heavy periods are affecting your well-being and lifestyle to such an extent that you need treatment.

These are the warning signs to take into consideration:

• You have to change your sanitary protection several times during the night.
• You need to change your sanitary protection every hour over several consecutive hours.
• You need to use both tampons and towels, or even nappies.
• You pass clots of blood.
• You have become anaemic.
• Your menstrual bleeding is prolonged.

Mr Andrew Prentice, consultant in obstetrics and gynaecology at the Rosie Maternity Hospital in Cambridge, says anyone can get heavier periods at any age, but it's usually women in their '40s who seek medical help for the problem.

Many women say that having children makes their periods heavier, but Prentice says there’s no evidence to back this up. ‘The truth is people don’t stay the same throughout their lives. Sometimes periods will get lighter, and sometimes heavier.’ Miss Jenny Higham, a gynaecologist at St Mary's Hospital, London, disagrees: ‘My research shows that the blood loss does increase with each pregnancy, up to a maximum of three pregnancies.’ The reasons for this aren’t clear, but Miss Higham says it’s possible that there’s an increase in the surface area of the endometrium (lining of the uterus), or an alteration of the blood flow to the uterus.

Why things get heavy

For many women there’s no obvious cause but a number of contributing factors:

• A change in hormonal balance: ‘For some women it can be explained by months when they don’t ovulate,’ says Prentice. ‘They don’t produce normal levels of progesterone, which changes the lining of the womb. They have irregular heavy periods.’
• Stress and upset can unsettle your hormone balance and cause a temporary change in your menstrual blood flow. This is particularly true amongst teenage girls who have immature pituitary and ovary glands.
• A hormonal imbalance can also be caused by problems in the ovary, thyroid and adrenal glands.

Polyps may have formed in the lining of the womb. Or there may be fibroids (benign lumps), which produce symptoms in at least 20% of premenopausal women.

Endometriosis - a disease where the lining of the womb grows outside of the cavity of the uterus.

Pelvic infection which in the long term affects periods in the same way as endometriosis. Intrauterine Contraceptive Devices (IUCDs): Having a coil fitted changes the environment of the uterus and may make periods heavier. In most cases the blood flow eventually returns to normal.

Dysfunctional uterine bleeding

If there are no hormonal imbalances or structural reasons for the blood loss, dysfunctional uterine bleeding may be diagnosed, often referred to as DUB. The probable cause lies within the womb lining, due to the production of abnormal amounts of the chemicals that control blood loss are produced.

Cancer

Very rarely there may be a cancer in the lining of the endometrium. If detected early it can be cured completely.

And not forgetting...

You may unknowingly have become pregnant and be experiencing an early miscarriage.

If you’ve been on the pill a long time, and then come off it, your periods will seem a lot heavier than before. This may be nothing unusual, simply that the pill had made them lighter and the blood flow has now returned to what it would normally have been.

What can be done?

Treatments depend on the cause of the excess bleeding. But Mr Andrew Prentice believes that at the moment, too many doctors are using ineffective treatments. In the British Medical Journal he states that, ‘More than a third of general practitioners prescribe norethisterone, (a contraceptive hormonal therapy based on progestogen) arguably the least effective option as first line treatment.’ The most effective form of treatment according to Prentice is tranexamic acid, a non-hormonal drug which reduces menstrual loss by half and is prescribed by only one in 20 doctors.

Of course treatments vary according to the needs of each patient. Your doctor will take into account your age, whether you need contraception, whether your period has a regular cycle and what your preferences are about taking oral contraceptives.

Drug Therapy

Painkillers may be the first treatment you?ll be offered. Drugs like ibuprofen can be taken during menstruation to work against the local hormones produced in the uterus which cause heavy periods. Stronger non-steroidal anti-inflammatory drugs such as mefenamic acid can reduce blood loss by 20% - 45%. if taken during menstruation.

There are other drugs available which also affect the bleeding mechanism. These are known as non-steroidal anti-inflammatory agents which, if taken during menstruation, can reduce blood flow in about 40% of cases.

You may also need to take an iron supplement to counter any anaemia.

Hormonal treatments

Progestogen or the contraceptive pill - can be effective for some women and comes with the added bonus that it controls an erratic menstrual cycle and provides protection against unplanned pregnancy.

Mirena coil - More recently doctors have been treating heavy periods by inserting a contraceptive coil called a Mirena, which produces a very small amount of the hormone, levonorgestrel, daily. This hormone is found in many contraceptive pills, but in the coil it?s delivered at a much lower dose (about one seventh the usual strength) and goes directly to the lining of the womb rather than reaching it?s destination via the blood stream. This reduces the normal side effects associated with oral contraceptives. The Mirena is very effective, reducing blood flow by 85% within three months. Eventually periods may stop completely in up to a third of women, which isn?t a medical problem, although some women may find their absence strange.

Endometrial Ablation: - This is an operation to remove the lining of the womb. A new lining doesn’t form in its place, so periods are either reduced or stop completely. There are several surgical procedures for this, involving either cutting the lining away, or destroying the tissue with lasers, heat or microwaves. As with all operations there are some risks, and a general anaesthetic is usually needed.

About 75% of women receiving this treatment are cured, but problems can recur later in life, and a further endometrial ablation could be required or a hysterectomy.

Hysterectomy

This is the most drastic treatment for heavy periods, involving the surgical removal of the uterus and in most cases the cervix. Because this operation results in sterility, it’s only suitable for women who don’t want to have more children and would only be recommended for extremely long and heavy periods, or if you have large fibroids. Hysterectomy really is the last resort for menorrhagia sufferers and it’s well worth consulting your GP or a specialist to see which other treatments could offer some monthly relief.