Is your monthly blood flow interfering with your quality of life?

Menorrhagia, or excessively heavy menstrual bleeding, can make life miserable for women. Some are afraid to leave their house during the first few days of their period out of fear of bleeding through their clothes.

Unfortunately, it is a very common problem. One-third of all women in the U.S. seek medical treatment for this condition, according to the College of Obstetricians & Gynecologists.

Gynecologist Eva Strobl, MD, at Cape Cod Hospital OB/GYN sees patients with menorrhagia almost every day at her Hyannis practice. She said women don’t have to suffer in silence.

“If it interferes with a patient’s quality of life, that’s enough of a reason to see a gynecologist and start treatment,” she said.

Common Causes

There are many causes of disordered bleeding. The most common ones, according to Dr. Strobl, are:

• Genetics
• Endometriosis
• Adenomyosis (endometriosis confined to the uterus)
• Polyps
• Fibroids
• Hormonal imbalances caused by conditions such as obesity and PCOS
• Hormonal imbalances caused by perimenopause or puberty

Less common reasons for disordered bleeding include:

• Thyroid disease
• Bleeding disorders
• Anticoagulation medications
• Pre-cancer or cancer

“Perimenopausal bleeding is definitely very common,” she said. “It has to do with that hormonal imbalance. As your progesterone and estrogen start to decline in perimenopause, they may not decline in a balanced fashion and then you have this dysfunctional, almost uncontrolled, bleeding because your hormone levels are too low to stop it.”

Another time that hormones can affect menstrual bleeding is when adolescents first start menstruating. In those cases, Dr. Strobl would start medications, typically hormonal birth control, to regulate the patient’s cycle.

When most patients come in with excessive bleeding, the first thing Dr. Strobl does is look for other treatable reasons besides hormonal ones. That can include an ultrasound to check for fibroids and polyps and a blood test to check for thyroid disease and anemia. Surgery is the only way to officially diagnose endometriosis or adenomyosis, so gynecologists have to base a possible diagnosis for those conditions on the prevalence of symptoms, not tests.

Hormonal Options

Both traditional birth control pills and progesterone-only birth control pills are good options for many patients. Arm implants and IUDs with progesterone are also good options. Some women take continuous birth control so they don’t get a period. That is particularly popular with younger patients, Dr. Strobl said.

“There is no medical reason that you need to get a period every month, so it is safe and reasonable, especially for patients with disordered bleeding,” she said. “Those hormones are regulating the growth of the lining of the uterus, so you don’t need to have a regular shedding of that lining when you are on these medications.”

Patients who choose to take continuous birth control to skip periods should take a week off if they start spotting. That is the body’s sign that they need to shed the uterine lining and get a period, said Dr. Strobl. Other patients take active birth control for three months at a time and then take a break and get a period every three months. That gives them somewhat of a predictable cycle but still improves their quality of life, she said.

“My preference with patients that are later in life is to prescribe progesterone, only, during your period to decrease blood loss, or a medication called TXA (Tranexamic Acid) that enhances the clotting cascade and helps to decrease blood loss during your period,” she said. “You typically only take those for one week out of the month.”

Surgical Options

The first line of treatment is typically medication, but if that doesn’t work, the side effects aren’t tolerated or the patient has a reason they either don’t want to take hormones or can’t take them, then surgery is the next consideration, according to Dr. Strobl. Since most of the medications are hormonal and contain estrogen patients with high blood pressure, a history of blood clots or tobacco use would have a higher risk of developing dangerous blood clots. They wouldn’t be able to take hormones, she said.

If a patient is done with childbearing and their symptoms are severe, a hysterectomy is always a possibility, but a less invasive option is to do an endometrial ablation.

“That’s typically reserved for patients in their 40s because if you do it at earlier ages, the effects aren’t long-lasting more than five to 10 years,” Dr. Strobl said. “The bleeding typically returns with that procedure unless you go through menopause within 10 years. But for perimenopausal patients, an ablation is a really good option because you are in the right age range and its minimally invasive. The recovery is maximum two weeks and patients generally do very well afterwards.”

An endometrial ablation is a same-day surgery that takes about 30 minutes in the operating room. Patients go home the same day and usually just need to take Tylenol or ibuprofen afterwards for pain for about a week.

“If it’s negatively impacting the quality of your life where you are not able to care for your family or you are having so much blood loss that you have anemia chronically, there’s definitely things we can do, whether it’s medications or minor surgical procedures,” Dr. Strobl said.