T.L. is a 42-year-old mother of two with a long history of heavy menstrual cycles. At times she was anemic, which left her exhausted. She was looking for answers, but wasn’t getting any meaningful relief.
Menorrhagia is the medical term for abnormally heavy menstrual cycles. At times, it can be so serious as to require a blood transfusion or even a hysterectomy (surgical removal of the uterus). The causes are varied and can be hormonal, such as in estrogen and progesterone imbalance. There can also be structural issues within the uterus, as in fibroids (benign growths). Uterine cancer or precancerous cells can also cause heavy bleeding. Other medical conditions, such as thyroid, kidney, or liver disease can be a contributing factor, as well as blood-clotting disorders.
In other words, it takes a full medical work-up to determine the cause and find a remedy.
T.L. has seen several other physicians over the past several years, all trying different treatments. The treatments for menorrhagia also depend on where the woman is in her reproductive life and what her desires are. T.L. had several small fibroids, but their location wasn’t the cause of her heavy periods. Fibroids are like real estate: It all depends on location, location, location. Her hemoglobin level was 8.6 grams per deciliter (normal is 12 to 15 g/dl). This was low, but not in the range of needing a blood transfusion.
Oral contraception pills, which contain estrogen and progesterone, had failed for T.L. Many times, they are a simple way to correct the heavy bleeding. T.L.’s ultrasound also showed what is known as adenomyosis. This is basically endometriosis of the walls of the uterus. Endometriosis is when the tissues that line the uterus grow outside the uterus. This can be very painful and cause heavy periods. In. T.L.’s case, this condition was concurrent with adneomyosis, another form of abnormal growth of uterine tissue.
Due to her adneomyosis, T.L. wasn’t a good candidate for an endometrial ablation, which is where heat energy is used to destroy the lining of the uterus to stop menstrual periods.
In a normal menstrual cycle, a woman bleeds every month. A normal cycle can vary from every 24 to 36 days, with the average being every 28 days. A woman normally ovulates around day 14 of a 28-day cycle. Ovulation is what helps to regulate bleeding. The number of bleeding days is usually five to seven days. The amount of bleeding is subjective, and when a woman feels it’s too heavy, we check her blood count, as we did with T.L.
Everyone defines heavy bleeding differently, but a simple measure is if a woman has to change her tampon or pad in less than two hours, or if she passes clots bigger than a quarter.
As stated, the causes that disrupt this regular pattern are varied. If you feel that your periods are too heavy, you should see your physician or nurse practitioner. He or she will start the work-up. A lot depends on how old you are and where you are in your family planning.
T.L. was complaining of very heavy periods. She wasn’t, however, complaining of bleeding in between her periods, which can also be a serious problem. (That’s for another article.)
T.L also tried taking nonsteroidal anti-inflammatory drugs (NSAIDs), such as Motrin, which can sometimes help with the pain and bleeding associated with adenomyosis. I don’t usually find much benefit from NSAIDs in cases such as T.L., and neither did she.
Now that you started the work-up with your health care provider, the pieces should start to fall into place. Provided there’s no blood clotting disorder or thyroid, liver, or kidney disease, the options for treatment are quite long and varied.
The simple treatment for young women is oral contraceptive pills, which can work wonders, though some women may want to avoid the potential side effects of long-term usage. Progesterone-only pills may also work.
For older women, after having a family, an endometrial ablation may work well.
For those women with fibroids, it all depends on location. Some fibroids are harmless, while others can be a serious problem. Removal of the specific offending fibroid may be required. In some cases, a complete hysterectomy needs to be performed. Each woman is different and requires a specific treatment. There’s no cookie-cutter solution.
T.L. was started on something called tranexamic acid (TXA). TXA works by blocking the breakdown of blood clots, which prevents bleeding. T.L. would take two pills of TXA every eight hours as soon as her period started. She would continue for five days. TXA can reduce the amount of bleeding by almost 50 percent when taken this way. T.L. did great with it, and her last hemoglobin level was 12.2 g/dl. She will stay on TXA for several years, and we will then reevaluate.
Many physicians use TXA in an emergency to stop a woman who is hemorrhaging after childbirth. It has saved many women from needing an emergency hysterectomy.
There are also newer medications out, such as Oriahnn and Myfembree, which can be used to decrease bleeding in women with fibroids.
Each of these medications, including the birth control pill, has risks. Everything is about the risk-benefit ratio. Avoiding any and all unnecessary surgery should be the goal. The bottom line is, when you have a problem such as heavy menstrual cycles, don’t be afraid to seek help. Also, never be afraid to ask questions or get a second opinion.
