One in five women bleeds so heavily during their periods that they have to put their normal lives on hold just to deal with the heavy blood flow. During a normal menstrual cycle, the average woman loses about 1 ounce (30 mL) of blood and changes her sanitary pads/tampon around 3 to 5 times per day. Bleeding is considered heavy if it interferes with normal activities. If you have heavy menstrual bleeding you may have to change a tampon or pad every hour, and/or menstrual bleeding lasts longer than 7 days in duration. Heavy menstrual bleeding can be common at various stages of your life—when you first begin to menstruate and in your late 40s or early 50s, as you get closer to menopause. If you are past menopause and experience any vaginal bleeding, discuss your symptoms with your doctor immediately. Any vaginal bleeding after menopause isn’t normal and should be evaluated immediately.

2. Heavy menstrual bleeding can be caused by:

• Hormonal imbalances
• Medical conditions 
• Structural abnormalities in the uterus, such as polyps or fibroids
• Abnormal pregnancy
• Infections

Hormonal Imbalance The most common cause of heavy menstrual bleeding is due hormonal imbalance. Your body may produce too much or not enough estrogen or progesterone—known as reproductive hormones necessary to keep your menstrual cycle regular. So any change in this will affect your cycle. Medical conditions can cause heavy menstrual bleeding;

• Thyroid problems
• Blood clotting disorders such as Von Willebrand’s disease, a mild-to-moderate bleeding disorder
• Idiopathic thrombocytopenic purpura (ITP), is a bleeding disorder characterized by too few platelets in the blood
• Liver or kidney disease
• Certain medications, such as anticoagulant drugs such as Plavix (clopidogrel) or heparin and some synthetic hormones
• Leukemia

Gynecologic conditions that may be responsible for heavy bleeding include:

• Complications from an IUD
• Fibroids
• Leukemia

Abnormal Pregnancy

• Miscarriage
• An ectopic pregnancy occurs when a fertilized egg begins to grow outside your uterus, typically in your fallopian tubes

Other causes of excessive bleeding include: 1. Infections 2. Precancerous conditions of the uterine lining cells

Absent Periods

Some may experience the opposite problem of heavy menstrual bleeding—no menstrual periods at all. This condition, called amenorrhea, or the absence of menstruation, is normal before puberty, after menopause, and during pregnancy. If you do not have a monthly period and do not fit into the above-mentioned situation, you need to get evaluated. There are two kinds of amenorrhea:

• Primary and
• Secondary

Primary amenorrhea is when you don’t get your first period by age 16. This may be caused by an issue with the endocrine system which regulates your hormones, or it might just be a delay in puberty which is commonly seen due to a delay in the maturation of the mentioned brain- ovaries – uterus axis. Secondary amenorrhea occurs when you had your regular periods and then stopped Common causes of primary amenorrhea and secondary amenorrhea in teens include:

• Stress
• Eating disorders
• Sudden weight gain or loss (excessive exercise, obesity)
• Thyroid abnormalities
• Ovarian cysts

When adults do not menstruate, the common causes are often different. These may include:

• Pregnancy
• Menopause
• Polycystic ovarian syndrome
• Medical conditions like thyroid problems, increased prolactin level
• Stopping birth control
• Pelvic inflammatory disease (a reproductive infection)
• Premature ovarian failure
• Ovarian cysts

Irregular periods You have irregular periods if the length of your menstrual cycle (the gap between your periods starting) keeps changing. It starts early or late and if occurs for more than 3 cycles it is better to consult with your gynecologist.

Causes of irregular periods

• Puberty – your periods might be irregular for the first year or two
• Start of the menopause (usually between the ages of 45 and 55)
• Early pregnancy – take a pregnancy test to rule this out
• Some types of hormonal contraception – such as the contraceptive pill or intrauterine system (IUS)
• Extreme weight loss or weight gain, excessive exercise or stress
• Medical conditions – such as polycystic ovary syndrome (PCOS) or a problem with your thyroid

Severe menstrual cramps (dysmenorrhea)

Most women have had menstrual cramps before or during their period in their lives. For some, it’s a regular occurrence. But if your cramps are especially painful and persistent, this is called dysmenorrhea, Pain from menstrual cramps is caused by uterine contractions, triggered by prostaglandins, hormone-like substances that are produced by the uterine lining cells and circulate in your bloodstream. Pain can typically last 12 to 72 hours, and you might have other symptoms, such as nausea and vomiting, fatigue, and even diarrhea. Commonly menstrual cramps may become less painful as you get older.

Diagnosis

If you experience any irregularities from the normal pattern of your cycle and it’s persisting for 2-3 cycles you should schedule an appointment with your health care professional. To prepare, keep a diary of the frequency and duration of your periods. Also jot down any additional symptoms, such as cramping, and be prepared to discuss health history. Nowadays there are so many mobile applications available that will help you to track and keep a record of your cycles. History Taking Your medical history is very important to know if your menstrual problem is caused by any medical condition. For example, abdominal pain might be due to appendicitis, urinary tract infections, ectopic pregnancy, and irritable bowel syndrome. Endometriosis and uterine fibroids may cause heavy bleeding and chronic pain. So a detailed history of your cycle, medical condition, family, current medication, sexual history, and contraceptive use will be taken by your doctor. An Abnormal & Pelvic Examination A pelvic exam is a standard part of the diagnosis. A Pap test may be done during this exam. Blood Tests Blood tests can help rule out other conditions that cause menstrual disorders. For example, your doctor may test thyroid function to make sure that low thyroid (hypothyroidism) is not present. Blood tests can also check follicle-stimulating hormone, estrogen, and prolactin levels. A urine test can be done to check if you are pregnant. Women who have heavy bleeding may get tested for anemia if needed for bleeding disorders as well. Ultrasound and Sonohysterography Imaging techniques are often used to detect certain conditions that may be causing menstrual disorders. Ultrasound is the standard imaging technique for evaluating the uterus and ovaries. It can help to detect fibroids, uterine polyps, ovarian cysts, and tumors Transvaginal sonohysterography is ideal in these conditions. Transvaginal sonohysterography uses ultrasound along with a probe (transducer) placed in the vagina. Sometimes saline (salt water) is injected into the uterus to enhance visualization. Other Diagnostic Procedures Endometrial Biopsy When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy may be performed in the OPD. This procedure can help identify abnormal cells, which suggest that pre-cancer or cancer may be present. It may also help the doctor decide on the best hormonal treatment to use. The procedure is done without anesthesia. Gentle suction removes a sample of the endometrial lining. The tissue collected is examined by a pathologist and is reported

1. Hysteroscopy

Hysteroscopy is a procedure that can detect the presence of fibroids, polyps, or other causes of bleeding. Hysteroscopy may be done either in an OPD or operating room setting and requires no incisions. A fiber-optic light source and a tiny camera in the tube allow the doctor to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This might cause cramping in some patients, in such cases, a NSAID can help prevent pain from this procedure. The patient can choose to in OT if she is having a low threshold for pain. Hysteroscopy is also often performed as part of other surgical procedures, such as dilation and curettage (C&D). Your doctor will counsel you before this procedure – regarding the method and what to expect.

1. Dilation and Curettage (D&C)

During a D&C, your cervix is dilated and instruments are used to scrape away your uterine lining. A D&C may also be used as a treatment for excessive bleeding and for bleeding that doesn’t respond to other treatments. It is performed on an outpatient basis under local anesthesia. A hysteroscopy is often performed at the same time as a D&C if endometrial mass or polyps are suspected

1. Laparoscopy

Diagnostic laparoscopy, an invasive surgical procedure, is used to diagnose and treat endometriosis, a common cause of dysmenorrhea. Laparoscopy normally requires a general anesthetic, although the patient can go home the same day. The procedure involves inflating the abdomen with gas through a small abdominal incision. A fiber-optic tube equipped with small camera lenses (the laparoscope) is then inserted. The surgeon uses the laparoscope to view the uterus, ovaries, tubes, and peritoneum (lining of the pelvis).

Treatment for the menstrual irregularities

Treatments range from over-the-counter medications to surgery, with varied treatments in between. Your doctor will suggest your mode of treatment depending on your diagnosis, its severity, your preferences, and your health history. Abnormal uterine bleeding Medication and surgery are the modes to treat Abnormal uterine bleeding. Typically, we start with oral medications. Treatment choices depend on your age, your desire to preserve fertility, and the cause of the abnormal bleeding (dysfunctional or structural). Some treatments may reduce your menstrual bleeding to light to normal flow. Medication Medication therapy is often successful and a good first option. The benefits last only as long as the medication is taken, so it might be a long-term commitment. Tranexamic acid or ethamsylate (haemostatic drugs), has been used successfully to decrease heavy menstrual bleeding. These tablets are only taken on the days you expect to have heavy bleeding Nonsteroidal anti-inflammatory drugs (NSAIDs) are over the counter and can help reduce menstrual bleeding and cramping. These medications include ibuprofen naproxen, and Mefenamic acid. Common side effects include stomach upset, headaches, dizziness, and drowsiness. Hormonal Treatments Low-dose birth control pills and progestins may help control heavy or irregular bleeding caused by hormonal imbalances. If your periods have stopped, oral contraceptives are highly effective in restoring regular bleeding. Both can also help reduce menstrual flow, improve and control menstrual patterns and relieve pelvic pain during menstruation. Medications that contain the synthetic estrogen, are the first birth control pill FDA-approved for the treatment of heavy menstrual bleeding due to hormonal imbalance. The combination estrogen-progesterone pill has additional for contraception as well. Birth control pills may not be an appropriate treatment choice if you smoke, or have a history of pulmonary embolism (blood clots in your lungs). So talk to your doctor about your habits. Progestrogens another hormone, either oral or injectable, are also used to manage heavy bleeding, particularly that resulting from a lack of ovulation. Although they don’t work as well as estrogen, they are effective for long-term management. Side effects include irregular menstrual bleeding, weight gain, and sometimes, mood changes. The levonorgestrel intrauterine system (Mirena) is FDA-approved to treat heavy menstrual bleeding in women who use intrauterine contraception as their method of birth control prevention. The Mirena system may be kept in place for up to five years. Over this time, it slowly releases a low dose of the progestin hormone levonorgestrel into the uterus. Mirena is also referred to as an intrauterine. Surgery Surgical options for heavy menstrual bleeding depend on whether you desire to retain your uterus or not. Hysterectomy is the surgical treatment of removing your uterus. Other options are those that retain your uterus but treat by removing the endometrial lining. However, these might affect your fertility. Risks common to all surgical options include infection, bleeding, etc. Mentioning a few options

• Endometrial ablation
• Endometrial resection
• Dilation and curettage (D&C)
• Myomectomy

Fibroids are a common cause of heavy bleeding, and removal of fibroids with a procedure called myomectomy usually resolves the problem. Depending on the size, number, and position of the fibroids, myomectomy may be performed with a hysteroscope, laparoscope, or through a bikini abdominal incision. Hysterectomy. This is one of the most common surgical procedures performed to end heavy bleeding. It is the only treatment that completely guarantees bleeding will stop. But it is also a major surgery that removes your uterus. it has its own risks and benefits which you have to talk about and discuss with your doctor. Menstrual Pain If you are having severe menstrual cramps called (dysmenorrhea) regularly, a doctor might suggest you try over-the-counter medications and exercise, among other strategies. Medications such as nonsteroidal anti-inflammatories (NSAIDs), like ibuprofen and mefenamic acid, can be purchased without a prescription. Treatment works best if started hours before the onset of cramping. If you wait until you have pain, it doesn’t work as well. This will also help reduce heavy bleeding. Oral contraceptive pills are also effective for menstrual cramps. Discuss with your doctor such options. Other ways to relieve symptoms include putting heat on your abdominal area and mild exercise.

Prevention for Menstrual Irregularities

You cannot prevent abnormal uterine bleeding, but you can manage it once it develops. Women who experience chronic ovulation problems—failure to ovulate—can regulate their bleeding by continuing to take oral contraceptives. For other menstrual cycle-related problems, such as cramping you can take steps to prevent or minimize your discomfort and pain. Additionally, changing your diet, exercising, and adopting a regular sleep pattern can all help with alleviating your bleeding irregularities Exercising at least 20 to 30 minutes three times a week, ideally for at least 30 minutes, five days a week. Sleeping consistent hours and establishing a bedtime routine to help cue your body and mind for sleep. This article is written by Dr.Navitha Aziz ( Specialist Gynecologist – WELLKINS Medical Centre )