Heavy menstrual bleeding (Menorrhagia)

Heavy menstrual bleeding, which is also known as menorrhagia is very common. This may be excessive bleeding to the tune of requiring to change the pads every hour for several hours or needing to wake up at night to change pads or bleeding that lasts longer than a week. 

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There are several causes for menorrhagia. 

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It may be due to hormonal imbalance which is very common in teenage girls, especially soon after the periods start.  Variations of the female hormones leading to menorrhagia can also occur when the ovary does not release an egg during the cycle (anovulation) or in patients with polycystic ovary syndrome (PCOS).  It could be due to fibroids, which is a common benign (non-cancerous) tumour of the smooth muscle layer of the womb (myometrium) or due to polyps which is a benign tumour of the lining of the womb (endometrium).  Less commonly it can be due to cancer of the womb. Early detection of this is very important to for successful treatment. Heavy menstrual bleeding can also be due to medical conditions like bleeding disorders, thyroid problems or the use of blood-thinning medications. 

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Since many different conditions can cause menorrhagia, a thorough assessment by the specialist is essential. In addition to a detailed face to face assessment, patients often need blood tests, ultrasound scans and cervical screening (which has replaced the pap tests) are required in most patients. A number of medicines can be used for treating menorrhagia. This includes anti-inflammatory medicines, tranexamic acid, hormone pills and hormone containing uterine devices (such as Mirena). Patients can develop anaemia due to blood loss and such patients may need iron tablets.  

 

Some procedures may be needed to accurately identify the cause of heavy menstrual bleeding or to treat the heavy menstrual bleeding.

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Hysteroscopy and endometrial biopsy: Here the doctor dilates the cervix and examines the inside of the womb with a camera and takes biopsy from any suspicious areas. This is a must in any patient who has some probability of having uterine cancer since it is essential for accurate detection of cancer. If any polyps are identified during the hysteroscopy that can be easily removed and will help the bleeding. 

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Endometrial ablation: The lining of the womb is removed using an electric current.  This can lead to lasting benefits in patients with heavy menstrual bleeding.  Though the womb is not removed in this procedure pregnancy is not recommended after endometrial ablation. 

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Myomectomy: is the removal of uterine fibroids only, leaving behind the uterus. Myomectomy is particularly useful in women who are contemplating pregnancy after the surgery. Myomectomy may be done through keyhole surgery or as an open surgery depending on a number of factors. 

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Hysterectomy: is the removal of the uterus and cervix. This will stop menstrual periods. Ovaries may be retained or removed depending on a number of factors. Removal of both ovaries and tubes is known as bilateral salpingo-oopherectomy. Removal of ovaries will cause menopause. Hysterectomy can be done by surgically opening the abdomen (abdominal hysterectomy), or using keyhole surgery (laparoscopic hysterectomy) or with assistance from a robot (robotically assisted hysterectomy). The recovery after laparoscopic and robotic surgery is much more rapid than open surgery. If the uterus is not markedly enlarged and there is room in the vagina, it is also possible to remove the uterus through a cut in the vagina (vaginal hysterectomy). The patient will not have any abdominal scars. A/Prof Bindu Murali is well versed with abdominal hysterectomy,  vaginal hysterectomy, laparoscopic hysterectomy or robotically assisted hysterectomy. The choice depends on the patient's medical situation and to some extent patient preferences. 

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