Menorrhagia is the medical term for menstrual periods with abnormally heavy or prolonged bleeding. It is an important cause of ill health in women . It is estimated that 9 to 30 percent of women of reproductive age suffer from menorrhagia, the prevalence increasing with age, and peaking just prior to menopause Menorrhagia has an impact on many women’s lives, with one in twenty women aged 30 - 49 with menorrhagia consulting their general practitioners each year. It has been found that once referred to a gynaecologist, 60% of women with menorrhagia will have a hysterectomy within five years, accounting for up to 75 percent of all hysterectomies performed worldwide.
Apart from surgery, medical therapy, appears to be an attractive treatment option, there being a wide variety of medication available to reduce heavy menstrual bleeding including non-steroidal anti-inflammatory drugs, hormones, anti-fibrinolytics, and intrauterine devices.
The signs and symptoms of menorrhagia may include:
• Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
• Needing to use double sanitary protection to control your menstrual flow
• Needing to wake up to change sanitary protection during the night
• Bleeding for longer than a week
• Passing blood clots with menstrual flow for more than one day
• Restricting daily activities due to heavy menstrual flow
• Symptoms of anemia, such as tiredness, fatigue or shortness of breath
According to FIGO classififcation, the causes of menorrhagia can be group into to the following ,
4. Malignancy and Hyperplasia
2. Ovulatory Dysfunction
5. Not yet classified
Patients who lose more than 80 mL of blood, especially repetitively, are at risk for serious medical sequelae. These women are likely to develop iron-deficiency anemia as a result of their blood loss. Menorrhagia is the most common cause of anemia in premenopausal women. This usually can be remedied by simple ingestion of ferrous sulfate to replace iron stores. If the bleeding is severe enough to cause volume depletion, patients may experience shortness of breath, fatigue, palpitations, and other related symptoms. This level of anemia necessitates hospitalization for intravenous fluids and possible transfusion and/or intravenous estrogen therapy. Patients who do not respond to medical therapy may require surgical intervention to control the menorrhagia.
For those with high risk of developing endometrial cancer and hyperplasia such as post menopausal, obesity, hypertension and tamoxifen therapy, a endometrial assessment needed via office biospy or and hysteroscopy examination and curetage.
Specific treatment for menorrhagia is based on a number of factors, including:
• Your overall health and medical history
• The cause and severity of the condition
• Your tolerance for specific medications, procedures or therapies
• The likelihood that your periods will become less heavy soon
• Your future childbearing plans
• Effects of the condition on your lifestyle
• Your opinion or personal preference
Drug therapy for menorrhagia may include:
• Iron supplements. If you also have anemia, your doctor may recommend that you take iron supplements regularly. If your iron levels are low but you're not yet anemic, you may be started on iron supplements rather than waiting until you become anemic.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).
• Tranexamic acid. Tranexamic acid (Lysteda) helps reduce menstrual blood loss and only needs to be taken at the time of the bleeding.
• Oral contraceptives. Aside from providing birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding.
• Oral progesterone. When taken for 10 or more days of each menstrual cycle, the hormone progesterone can help correct hormone imbalance and reduce menorrhagia.
• The hormonal IUD (Mirena). This intrauterine device releases a type of progestin called levonorgestrel, which makes the uterine lining thin and decreases menstrual blood flow and cramping.
If you have menorrhagia from taking hormone medication, you and your doctor may be able to treat the condition by changing or stopping your medication.
You may need surgical treatment for menorrhagia if drug therapy is unsuccessful. Treatment options include:
• Uterine artery embolization. For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply.
During uterine artery embolization, the surgeon passes a catheter through the large artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with microspheres made of plastic.
• Focused ultrasound ablation. Similar to uterine artery embolization, focused ultrasound ablation treats bleeding caused by fibroids by shrinking the fibroids. This procedure uses ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure.
• Myomectomy. This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
• Endometrial ablation. Using a variety of techniques, your doctor permanently destroys the lining of your uterus (endometrium). After endometrial ablation, most women have much lighter periods. Pregnancy after endometrial ablation can put your health at risk — if you have an endometrial ablation, you should use reliable or permanent contraception until menopause.
• Endometrial resection. This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding. Pregnancy isn't recommended after this procedure.
• Hysterectomy. Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. Hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.
Dr. Liew Kean Chiew, is a Consultant Obstetrician & Gynaecologist at Pantai Hospital Penang. Dr. Liew received his undergraduate medical education from the University of Malaya in 2004. He then served as House Officer at the Hospital Ipoh in 2005, and subsequently worked as a Medical Officer in O&G at various well-established government hospitals (Hospital Parit Buntar & Hospital Taiping) in 2005-2008, before pursuing his postgraduate studies at the Universiti Sains Malaysia.
In year 2009, Dr. Liew started O&G training in Hospital Ipoh, and subsequently worked as O&G Master Trainee in Hospital HUSM. In year 2013, he obtained Masters in Mmed from Universiti Sains Malaysia and subsequently gazetted as O&G specialist. In year 2016, he was certified by the National Specialist Registry in the fields of Obstetrician and Gynaecology. Dr. Liew Kean Chiew lectures for University Malaysia Sabah during his service at Sabah Children and Women Hospital.
With vast working experience and extensive clinical research in Obstetrician and Gynaecology, Dr. Liew is competent in various areas of that field. He has special interest in Laparoscopic surgery and also urogynacological treatment. His areas of specialty include Pre Pregnancy Assessment, Antenatal (Pregnancy) Care, 3D Scan Fetal Anomaly Screening (including Nuchal Translucency), Labour and Normal Delivery & Caesarean Section, Fertility Treatment & Intrauterine Insemination (IUI), Laparoscopy Gynae Surgery, Women Health Screening, Gynaecology Consultation & Surgery, Family Planning Consultation & Treatment.