Menorrhagia

• Occurs every 21 to 35 days
• Lasts four to five days
• Produces a total blood loss of about 2 to 3 tablespoons (30 to 44 milliliters)

The menstrual cycle isn't the same for every woman. Your period may be regular or irregular, light or heavy, painful or pain-free, long or short and still be considered normal. Menorrhagia refers to losing about 5 1/2 tablespoons (81 milliliters) or more of blood during your menstrual cycle.

The signs and symptoms of menorrhagia may include:

• Menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours
• The need to use double sanitary protection to control your menstrual flow
• The need to change sanitary protection during the night
• Menstrual periods lasting longer than seven days
• Menstrual flow that includes large blood clots
• Heavy menstrual flow that interferes with your regular lifestyle
• Tiredness, fatigue or shortness of breath (symptoms of anemia)

Causes

In some cases, the cause of heavy menstrual bleeding is unknown, but a number of conditions may cause menorrhagia. Common causes include:

• Hormonal imbalance. In a normal menstrual cycle, a balance between the hormones oestrogen and progesterone regulates the buildup of the lining of the uterus (endometrium), which is shed during menstruation. If a hormonal imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding.
• Dysfunction of the ovaries. Lack of ovulation (anovulation) may cause hormonal imbalance and result in menorrhagia.
• Uterine fibroids. These noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.
• Polyps. Small, benign growths on the lining of the uterine wall (uterine polyps) may cause heavy or prolonged menstrual bleeding. Polyps of the uterus most commonly occur in women of reproductive age as the result of high hormone levels.
• Adenomyosis. This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and pain. Adenomyosis is most likely to develop if you're a middle-aged woman who has had many children.
• Intrauterine device (IUD). Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for birth control. When an IUD is the cause of excessive menstrual bleeding, you may need to remove it.
• Pregnancy complications. A single, heavy, late period may be due to a miscarriage. If bleeding occurs at the usual time of menstruation, however, miscarriage is unlikely to be the cause. An ectopic pregnancy — implantation of a fertilized egg within the fallopian tube instead of the uterus — also may cause menorrhagia.
• Cancer. Rarely, uterine cancer, ovarian cancer and cervical cancer can cause excessive menstrual bleeding.
• Inherited bleeding disorders. Some blood coagulation disorders — such as von Willebrand's disease, a condition in which an important blood-clotting factor is deficient or impaired — can cause abnormal menstrual bleeding.
• Medications. Certain drugs, including anti-inflammatory medications and anticoagulants (to prevent blood clots), can contribute to heavy or prolonged menstrual bleeding. Improper use of hormone medications also can cause menorrhagia.
• Other medical conditions. A number of other medical conditions, including pelvic inflammatory disease (PID), thyroid problems, endometriosis, and liver or kidney disease, may cause menorrhagia.

Risk factors

Menorrhagia is most often due to a hormonal imbalance that causes menstrual cycles without ovulation. In a normal cycle, the release of an egg from the ovaries stimulates the body's production of progesterone, the female hormone most responsible for keeping periods regular. When no egg is released, insufficient progesterone can cause heavy menstrual bleeding.

Menstrual cycles without ovulation (anovulatory cycles) are most common among two age groups:

• Adolescent girls who have recently started menstruating. Girls are especially prone to anovulatory cycles in the first year and a half after they have their first menstrual period (menarche).
• Older women approaching menopause. Women ages 40 to 50 are at increased risk of hormonal changes that lead to anovulatory cycles.

Complications

Excessive or prolonged menstrual bleeding can lead to other medical conditions, including:

• Iron deficiency anemia. In this common type of anemia, your blood is low on haemoglobin, a substance that enables red blood cells to carry oxygen to tissues. Low haemoglobin may be the result of insufficient iron. Menorrhagia may deplete iron levels enough to increase the risk of iron deficiency anemia. Signs and symptoms include pallor, weakness and fatigue. Although diet plays a role in iron deficiency anemia, the problem is complicated by heavy menstrual periods. Most cases of anemia are mild, but even mild anemia can cause weakness and fatigue. Moderate to severe anemia can also cause shortness of breath, rapid heart rate, lightheadedness and headaches.
• Severe pain. Heavy menstrual bleeding is often accompanied by menstrual cramps (dysmenorrhea). Sometimes the cramps associated with menorrhagia are severe enough to require prescription medication or a surgical procedure.

Diagnosis

Your doctor will most likely ask about your medical history and menstrual cycles. You may be asked to keep a diary of bleeding and nonbleeding days, including notes on how heavy your flow was and how much sanitary protection you needed to control it. Your doctor will do a physical exam and may recommend one or more tests or procedures such as:

• Blood tests. A sample of your blood is evaluated in case excessive blood loss during menstruation has made you anemic. Tests may also be done to check for thyroid disorders or blood-clotting abnormalities.
• Pap test. Your doctor collects cells from your cervix for microscopic examination to detect infection, inflammation or changes that may be cancerous or may lead to cancer.
• Endometrial biopsy. Your doctor takes a sample of tissue from the inside of your uterus to be examined under a microscope.
• Ultrasound scan. This imaging method uses sound waves to produce images of your uterus, ovaries and pelvis.

Based on the results of your initial tests, your doctor may recommend further testing, including:

• Sonohysterogram. This ultrasound scan is done after fluid is injected through a tube into the uterus by way of your vagina and cervix. This allows your doctor to look for problems in the lining of your uterus.
• Hysteroscopy. A tiny tube with a light is inserted through your vagina and cervix into the uterus, which allows your doctor to see the inside of your uterus.
• Dilation and curettage (D and C). In this procedure, your doctor opens (dilates) your cervix and then inserts a spoon-shaped instrument (curet) into your uterus to collect tissue from the uterine lining. This tissue is examined in the laboratory.

Doctors can be certain of a diagnosis of menorrhagia only after ruling out other menstrual disorders, medical conditions or medications as possible causes or aggravations of this condition.

References

http://emedicine.medscape.com/article/255540-overview

http://www.webmd.com/women/guide/heavy-period-causes-treatments

http://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html

http://www.nhs.uk/conditions/Periods-heavy/Pages/Introduction.aspx

http://www.bupa.co.uk/health-information/directory/m/menorrhagia