Social and Emotional Consequences of Abnormally Heavy Periods

Missing social or athletic events

Avoiding sexual activities

Missing work

Depression or moodiness

Feeling anxious

Lack of confidence

Features of Normal Menstrual Blood Loss

  • Regular cycle
  • Duration of 4 - 7 days
  • Cycle of 28 days (range 26 – 32)
  • Not excessively heavy
    • (this can be quite relative as what is considered to be heavy by one woman might be considered to be normal by another).
  • ± Passage of small clots
  • Not excessively painful
  • No bleeding inbetween period
  • No bleeding during or after intercourse

(After the menopause there should be no vaginal bleeding. Any noted bleeding, however slight and of any colour whether it be a dark brown stain or a bright loss, should be regarded as abnormal and urgent medical advice should be sought).

Types of Abnormal Uterine Bleeding

(Most problems with genital bleeding in women are a result of uterine function. Occasionally abnormal bleeding results from problems relating to vaginal, vulval, cervical or Fallopian tube problems)

Menorrhagia

  • Heavy ± prolonged, regular menstrual blood loss. The amount of blood loss is a very subjective issue. What one woman finds to be ‘normal’ another may consider to be ‘heavy.’ In technical terms, any blood loss greater than 80ml during any menstrual period would be considered to be abnormally heavy. In clinical practice the volume of menstrual blood loss is rarely measured.

Polymenorrhoea

  • Frequent ± prolonged periods where the amount of blood loss is considered to be normal. This usually indicates a cycle length of less than 26 days.

Polymenorrhagia

  • Frequent, heavy ± prolonged heavy periods. This usually indicates a cycle length of less than 26 days.

Oligomenorrhoea

  • Infrequent ± light menstrual blood loss.

Amenorrhoea

  • Complete absence of periods.

Intermenstrual bleeding

  • Bleeding that occurs between the normal menstrual periods. The definition does not take into account the degree of blood loss.

Postcoital bleeding

  • Bleeding that occurs after intercourse.

If you are wondering if the amount of menstrual blood loss that you experience is normal or excessive then perhaps you can consider the following questions:

Do your periods last a long time?

Is your bleeding so heavy that you need to change your tampons/pads every 1-2 hours?

Do you use a tampon and wear a pad at the same time?

Do you need to change your pads at night, stain the sheets or your clothing?

The physical effects of abnormally heavy periods can include

Extreme tiredness.

Anaemia.

Headaches.

Nausea.

Bad cramping (abdomino-pelvic).

 

The Process of Determining the Cause of Problem Genital Tract Bleeding

History:

  • Cycle duration and length
  • Number of pads used
  • History of flooding and clots
  • Ask specifically about intermenstrual and postcoital bleeding
  • Duration of the problem
  • Past gynaecological and obstetric history (including timing and results of last cervical smear, method of contraception and last menstrual bleeding)
  • Medical, surgical and drug history

Clinical Examination:

  • Anaemia
  • Goitre
  • Presence of abdominal mass?
  • Rectal examination
  • Genitalia;
    • Quality and oestrogenisation of tissues
    • Evidence of vaginal wall prolapse
    • Cervix (polyps/erosions)
    • Uterine size and mobility

Blood Picture Examination:

  • Complete blood picture
  • Liver function tests
  • Renal function tests
  • Thyroid function tests

More specialized tests such as:

  • Iron binding studies
  • Clotting studies
  • Urine tests;
    • Dipstick urine test (Microscopic haematuria)
    • Mid stream specimen of urine (Urinary tract infection)
    • Urine cytology (abnormal bladder cells)
  • Histological (tissue specimen) tests
    • Endometrial biopsy
    • Cervical biopsy
  • Protoscopy and Sigmoidoscopy
  • Cystoscopy
  • Laparoscopy
  • Hysteroscopy
    • Considered to be the gold standard investigation of the endometrial cavity as it allows for direct visualization which can be followed by target biopsy.

 

Endometrial: image 1 of 3 thumb Endometrial: image 2 of 3 thumb Endometrial: image 3 of 3 thumb

Radiological Investigations:

  • Abdominal and pelvic X-rays
  • Ultrasound scan of pelvis, abdomen and renal tract
  • CAT scan
  • MRI

Causes of Abnormal Menstrual Bleeding

Hormonal:

  • Changes in cycle related to age
  • Non specific changes
  • Changes related to presence or absence of ovulatory and non-ovulatory cycles

Benign lesions:

  • Endometrial polyps
  • Cervical polyps
  • Adenomyosis
  • Pelvic Inflammatory Disease
  • Endometriosis
  • Fibroids
  • Pelvic Inflammatory Disease
  • Endometriosis
  • Fibroids
Click To Enlarge
  • Submucous
  • Subserosal
  • Intramural

Uterine abnormalities enlarging the cavity - e.g. A double uterus

Click To Enlarge

Cancerous lesions:

  • Cervix
  • Uterus
  • Fallopian tubes
  • Ovaries
  • Vagina
  • Vulva
  • Bladder

Drugs:

  • The combined oral contraceptive pill
  • The progesterone only pill
  • Implanted or inserted progesterone only devices
  • Anticoagulants such as Warfarin
  • Intrauterine contraceptive devices
  • Hormone replacement therapy (HRT)

Endometrial Ablation

  • Mininal invasive technique used to destroy the endometrium (lining of the uterus which is shed during menstruation)
  • These techniques are usually done as daycase procedures involving a short general anaesthetic
  • No incisions are required and recovery is speedy with a rapid return to normal activities
  • Outcomes
    • 80-90% satisfaction with overall outcome
    • 15-50% having no further menstrual bleeding
    • 60-70% reporting lighter, shorter and more manageable periods
    • 15-35% will undergo a further endometrial ablation or will proceed to hysterectomy
  • Some endometrial ablation techniques can be repeated if avoidance of hysterectomy is a priority.
  • These techniques are only suitable for women who have completed their families as the endometrium is rendered inhospitable to future pregnancy (and hence effective contraception is essential).
  • Intercourse should be avoided for 4-6 weeks after surgery.
  • Patients can experience lower abdominal cramping discomfort for a few days and some will get a watery vaginal discharge that can last up to 4 weeks.
  • Occasionally some women experience an offensive vaginal discharge which resolves after treatment with antibiotics.
  • Endometrial ablation is usually combined with hysteroscopic assessment of the endometrium and endometrial biopsy to exclude non-benign causes of the heavy bleeding and to ensure that there are no lesions within the endometrial cavity that would be a contraindication for performing the endometrial ablation

Endometrial ablation is not a form of sterilisation. It is important to ensure that an effective means of contraception is maintained

Contraindications to endometrial ablation:

  • Uterine malignancy
  • Pre-malignant conditions of the endometrium such as unresolved hyperplasia
  • The presence of an intrauterine contraceptive device
    • These can be removed prior to assessment of the endometrial cavity with a hysteroscopy followed immediately by endometrial ablation if there are no other contraindications
  • Desire for future pregnancy
    • Pregnancies following endomtrial ablation have a higher rate of ending in miscarriage, preterm labour and can be more hazardous for the mother and fetus
  • Currently pregnant
  • Acute pelvic or urinary tract infection at the time of the procedure
  • i.e
    • Cystitis, salpingitis, endometrisis, vaginitis or cervicitis
  • Excessive endometrial cavity length
    • The maximum cavity length for most endometrial ablation devices is 10cm

Types of endometrial ablation systems:

  • First Generation Endometrial Ablation Therapy (FEAT)
    • Transcervical resection of endometrium
    • Rollerball
    • Laser
  • Second Generation Endometrial Ablation Therapy (SEAT)
    • Thermal balloons
    • Hot fluid circulation
    • Laser devices
    • Cryosurgery
    • Microwave
    • Monopolar electrical devices
    • Bipolar electrical devices

There are a number of different systems produced by a variety of companies.

The 3 most commonly used systems in Australia are Thermachoice®, Novasure® and Cavaterm®

Hysterectomy

  • Involves removal of the uterus
  • Does not involve removal of the ovaries unless specified separately
  • Does not involve changes to the hormonal profile (unless the ovaries are removed in a woman who has not had her menopause)
  • Can bring forward the time of natural cessation of ovarian functions (menopause) by 0 – 18 months depending on the individual woman
  • Inpatient stay from 1 - 5 days depending on individual recovery, surgeon and other surgery performed
  • Recovery 2-6 weeks depending on technique, individual background health and occupation
  • Can be combined with other pelvic/vaginal procedures:
    • Vaginal wall repair
    • Urinary Incontinence surgery
    • Laser Vaginal Rejuvenation
    • Designer Laser Vaginoplasty

Indications:

  • Abnormal menstrual bleeding
    • Usually prolong ± heavy bleeding not responsive to conservative measures
  • Enlarged uterus
  • Uterine prolapse
  • Genital tract cancer
    • Cervical
    • Uterine
    • Ovarian
    • Fallopian tube

Types of hysterectomy:

  • Total abdominal
    • Removal of uterus and cervix from open surgery
  • Subtotal
    • Removal of uterus with preservation of cervix most commonly during open surgery but occasionally during vaginal or laparoscopic surgery
  • Total laparoscopic
    • Keyhole surgical removal of uteru (and usually the cervix)
  • Laparoscopically assisted
    • Combined laparoscopic and vaginal technique to remove uterus (± cervix)
  • Vaginal
    • Vaginal route to remove uterus (± cervix)