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Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics)

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Andrew M Kaunitz, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Sandy J Falk, MD, FACOG
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INTRODUCTION

In a normal menstrual cycle, a woman loses an average of 2 to 3 tablespoons (35 to 40 milliliters) of blood over four to eight days. However, some women lose a lot more blood. This is referred to as heavy or prolonged menstrual bleeding, and has also been called menorrhagia. Most women have a menstrual period every 24 to 38 days (that is, the time from the first day of one menstrual period to the onset of the next); the average is every 28 days.

Women who lose 5 to 6 tablespoons (about 80 milliliters) of blood or more during their menstrual period are said to have heavy or prolonged menstrual bleeding. Losing a lot of blood during the menstrual period can cause medical problems such as anemia (low red blood cell count).

There are several treatments for heavy bleeding. More detailed information about heavy menstrual bleeding is available by subscription. (See "Management of abnormal uterine bleeding".)

CAUSES OF HEAVY OR PROLONGED MENSTRUAL BLEEDING

The most common causes of excessive menstrual bleeding are:

Not ovulating once per month (called anovulation)

Having abnormal tissue in the uterus, such as polyps, fibroids, or adenomyosis

Having a condition that increases bleeding throughout the body

Anovulation — Anovulation occurs when your ovaries do not produce and release an egg (ovulate) once per month. This causes your menstrual period to be irregular or absent. Anovulation is common in adolescents and in women who are near menopause. Women with polycystic ovary syndrome (PCOS) often do not ovulate regularly. (See "Patient education: Absent or irregular periods (Beyond the Basics)".)

Abnormal tissue in the uterus — Noncancerous growths in the uterus can cause heavy menstrual bleeding. The most common noncancerous growths are:

Polyps, which are small, grape-like growths of the lining (cavity) of the uterus

Fibroids (see "Patient education: Uterine fibroids (Beyond the Basics)")

Adenomyosis, in which uterine lining tissue grows into the muscular wall of the uterus

Overgrowth of the lining of the uterus (called endometrial hyperplasia, which can be a precursor to uterine cancer)

Bleeding tendency — Women with certain bleeding conditions or who take certain medicines can have heavy menstrual bleeding. Examples include:

von Willebrand disease (see "Patient education: von Willebrand disease (Beyond the Basics)")

Having a low platelet count

Taking a blood thinner, such as warfarin (see "Patient education: Warfarin (Coumadin) (Beyond the Basics)")

SYMPTOMS OF HEAVY OR PROLONGED MENSTRUAL BLEEDING

Women with heavy or prolonged menstrual bleeding typically have one or more of the following:

Soak through a pad or tampon every one or three hours on the heaviest days of the period

Have bleeding for more than seven days

Need to use both pads and tampons at the same time due to heavy bleeding

Need to change pads or tampons during the night

Pass blood clots larger than 1 inch (about 2.5 centimeters)

Iron deficiency anemia (see "Patient education: Anemia caused by low iron in adults (Beyond the Basics)")

When to seek help — If you soak through two pads or tampons in one hour for two hours in a row, call your healthcare provider or go to the emergency department. Bleeding this heavily can be serious or even life threatening.

DIAGNOSIS OF HEAVY OR PROLONGED MENSTRUAL BLEEDING

If you have heavy menstrual bleeding, your healthcare provider will want to perform a physical exam, including a pelvic exam. The healthcare provider might recommend other tests, based on what he or she finds during the exam. This can include:

Blood tests to look for anemia, thyroid disease, or a bleeding disorder.

A pelvic ultrasound (usually performed through the vagina), which uses sound waves to create a picture of the uterus and ovaries. An ultrasound can detect endometrial polyps and fibroids. A specialized pelvic ultrasound called sonohysterogram or saline infusion sonogram involves placing a small flexible tube through the vagina into the uterus to infuse a small amount of sterile water into the cavity of the uterus.

A biopsy of the tissue inside of the uterus, called an endometrial biopsy. This can be done in the office.

A hysteroscopy, which uses a small telescope to look inside the uterus.

MEDICAL TREATMENT FOR HEAVY OR PROLONGED MENSTRUAL BLEEDING

The best treatment of heavy menstrual bleeding for you will depend on:

The cause of your bleeding

Your preferences

Whether you need to prevent pregnancy

Your desire to have children in the future

Your healthcare provider will probably recommend treatment with one or more medicines first. If these treatments do not reduce bleeding enough, a surgical treatment might be an option (see 'Surgery for heavy or prolonged menstrual bleeding' below).

Hormonal birth control — Hormonal methods of birth control which may be used to treat heavy menstrual bleeding include the pill, skin patch, vaginal ring, shot, and hormonal intrauterine device (IUD). These treatments reduce bleeding during your menstrual period. Hormonal birth control can also reduce cramps and pain during your period. It might take three months for bleeding to improve after you start taking hormonal birth control.

Some forms of hormonal birth control, including the pill, skin patch, and vaginal ring, are designed to be used for three weeks in a row, followed by one week off. During the fourth week, you will have bleeding.

More information about hormonal birth control is available separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

Some doctors and nurses advise women with heavy menstrual periods to take hormonal birth control continuously, without a break week. If you take this approach, you will not have monthly menstrual cycles. This strategy is called continuous dosing.

Several brands of birth control pills are packaged with 3 months of pills to make it easier to take the pill continuously (table 1). You can also take other types of hormonal birth control continuously. This is explained in detail separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)", section on 'Continuous dosing'.)

Hormonal intrauterine device — There is an IUD that slowly releases a hormone, progestin, into the uterus. There is no estrogen in the IUD. This device is called Mirena or Liletta in the United States and in other countries. The IUD prevents pregnancy and reduces menstrual bleeding for up to five years (picture 1). A healthcare provider places the IUD inside the uterus. This treatment is best for women who do not want to become pregnant in the next six months. The most common side effect of the hormonal IUD is irregular bleeding; this is usually light bleeding or spotting. This usually improves after the first several months after IUD placement. In women who use a hormonal IUD specifically to treat heavy bleeding, expulsion rates (when the uterus pushes the IUD into an improper position or completely out of the uterus) are high. (See "Patient education: Long-acting methods of birth control (Beyond the Basics)", section on 'Intrauterine device (IUD)'.).

Shot — Depot medroxyprogesterone acetate (brand name: Depo-Provera) is a long-acting form of a progesterone-like hormone, called a progestin. It is a shot given once every three months. This treatment prevents pregnancy and can reduce heavy menstrual bleeding. The shot is best for women who do not want to become pregnant in the next year or longer.

The most common side effect of medroxyprogesterone acetate is bleeding and spotting, particularly during the first few months. Many women completely stop having menstrual periods after using this treatment for one year. More detailed information about medroxyprogesterone acetate is available separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)", section on 'Injectable birth control'.)

Antifibrinolytic medicines — Antifibrinolytic medicines can help to slow menstrual bleeding quickly. These medicines work by helping the blood clotting system. Examples include tranexamic acid (brand name: Lysteda).

The advantages of antifibrinolytic medicines over other medical treatments are that:

The medicine slows bleeding quickly (within two to three hours)

You need to take the medicine only a few days each month

The medicines do not affect your chances of becoming pregnant

Side effects can include headache and muscle cramps or pain. You should not take antifibrinolytic medicines with hormonal birth control unless your healthcare provider approves; there is controversy regarding a possible increased risk of blood clots, stroke, and heart attack when taken together.

Nonsteroidal antiinflammatory drugs (NSAIDs) — Nonsteroidal antiinflammatory drugs, such as ibuprofen (brand name: Motrin and Advil) and mefenamic acid (brand name: Ponstel), can help reduce menstrual bleeding and menstrual cramps. You can buy some NSAIDs (including ibuprofen) without a prescription.

NSAIDs are not expensive, have few side effects, and reduce pain and bleeding, and you need to take them only during your menstrual period. You can take NSAIDs in combination with any of the medical treatments discussed here. However, NSAIDs do not reduce bleeding as well other medical treatments.

Progestin pills — Norethindrone acetate or medroxyprogesterone in pill form (brand name: Provera) can also be taken as a pill. Progestin pills are sometimes recommended for women who do not ovulate regularly. They may be prescribed for 5 to 14 days each month, or continuously (every day).  

This treatment helps to prevent the lining of the uterus from becoming thickened, which can cause excessive bleeding.

Gonadotropin-releasing hormone (GnRH) agonists — GnRH agonists are a type of medicine that can be used to temporarily reduce menstrual bleeding. This treatment might be recommended for women who are waiting to have a surgical treatment.

These medicines work by "turning off" the ovaries, causing a temporary menopause. The medicines can be taken for up to six months. Side effects may include hot flashes and vaginal dryness as might otherwise be experienced by a menopausal woman. GnRH agonists are not usually recommended for longer than six months in a row due to the risk of weakened bones when used for long periods of time.

SURGERY FOR HEAVY OR PROLONGED MENSTRUAL BLEEDING

For women who have growths in the uterus, such as polyps or fibroids, having a treatment to remove the growth can reduce or end heavy bleeding.

Fibroids can be treated by removing them (called myomectomy) or cutting off their blood supply (called uterine artery embolization). These procedures are discussed in depth in a separate article. (See "Patient education: Uterine fibroids (Beyond the Basics)".)

Other surgical treatments for menorrhagia include:

Endometrial ablation — Endometrial ablation is a treatment that destroys or removes most of the lining of the uterus. This can reduce heavy menstrual bleeding or cause you to stop having menstrual bleeding. It is not a good option for women who might want to become pregnant in the future and may not be appropriate for women whose abnormal bleeding is caused by anovulation. The cause of the bleeding should be identified before endometrial ablation is performed.

The treatment can be done in the office or as a day surgery. After the treatment, most women have some cramping, vaginal discharge, and nausea. You may have a pinkish vaginal discharge for two to three days afterward; this gradually becomes clear and watery and can last for 2 to 10 days. Most women can go back to work or school the following day. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

Hysterectomy — Hysterectomy is a surgery that removes the uterus. This is a permanent treatment that cures heavy menstrual bleeding. However, the surgery can have complications and may require up to six weeks for full recovery. Pregnancy is not possible after hysterectomy. More detailed information about hysterectomy is available separately. (See "Patient education: Abdominal hysterectomy (Beyond the Basics)" and "Patient education: Vaginal hysterectomy (Beyond the Basics)".)

WHICH TREATMENT IS RIGHT FOR ME?

There are many treatments for heavy menstrual bleeding, and it can be hard to decide which one is right.

Step one — In most cases, you should start with a medical treatment (using a medicine).

If you would like to become pregnant in the next several months, a nonsteroidal antiinflammatory or antifibrinolytic medicine might be a good option (see 'Nonsteroidal antiinflammatory drugs (NSAIDs)' above and 'Antifibrinolytic medicines' above).

If you would like to have children eventually, but not soon, a hormonal birth control method, hormonal IUD, or shot might be a good option (see 'Hormonal birth control' above).

If you have no plans to become pregnant in the future, you can use any of the medical treatments described above. Hormonal birth control (including the IUD) and antifibrinolytic medicines are probably the most effective medical treatments.

Step two — If you have tried one or more medicines and you still have heavy menstrual bleeding, talk to your healthcare provider. A surgical treatment might be a good option in this case (see 'Surgery for heavy or prolonged menstrual bleeding' above).

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Heavy periods (The Basics)
Patient education: Immune thrombocytopenia (ITP) (The Basics)
Patient education: Endometrial ablation (The Basics)
Patient education: Uterine adenomyosis (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Absent or irregular periods (Beyond the Basics)
Patient education: Uterine fibroids (Beyond the Basics)
Patient education: von Willebrand disease (Beyond the Basics)
Patient education: Warfarin (Coumadin) (Beyond the Basics)
Patient education: Anemia caused by low iron in adults (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Long-acting methods of birth control (Beyond the Basics)
Patient education: Care after gynecologic surgery (Beyond the Basics)
Patient education: Abdominal hysterectomy (Beyond the Basics)
Patient education: Vaginal hysterectomy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

An overview of endometrial ablation
Management of abnormal uterine bleeding
Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)
Hormonal contraception for suppression of menstruation
Approach to abnormal uterine bleeding in nonpregnant reproductive-age women
Differential diagnosis of genital tract bleeding in women
Overview of treatment of uterine leiomyomas (fibroids)
Postmenopausal uterine bleeding

The following organizations also provide reliable health information.

National Library of Medicine

     (http://www.nlm.nih.gov/medlineplus/)

ACKNOWLEDGMENT

The editorial staff at UpToDate would like to acknowledge Howard Zacur, MD, who contributed to an earlier version of this topic review.

Literature review current through: Nov 2016. | This topic last updated: Tue Jun 14 00:00:00 GMT+00:00 2016.
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All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.