Menorrhagia may be defined as a heavy menstrual bleeding over several cycle. The traditional, objective, definition of menorrhagia is of menstrual blood loss of 80 ml or more per cycle. Measured blood loss has been shown to have little correlation with women’s own perceptions of bleeding heaviness and so the clinical definition typically used is that of excessively heavy bleeding for an individual.
In practice, any blood loss that is perceived by a women to be excessive or as having a negative impact on her quality of life warrants counseling and possibly treatment.
A significant population of women complaining of Menorrhagia will have a measured blood loss less than 80 ml per cycle. Menorrhagia is a major reason for gynecological referral. Various methods have been developed for the objective assessment of menstrual loss. These have not been very helpful in the clinical management of Menorrhagia.
Menorrhagia may start anytime from menarche through the reproductive years to menopause and in the postmenopausal women on hormone replacement therapy. It can start suddenly or run a chronic course.
During the normal menstrual cycle, proliferation of endometrium is induced by the effect of oestrogens, while progestogens induce secretory differentiation. For menstruation to occur there is extensive arteriolar vasoconstriction and bleeding occurs as vessels dilate.
The causes of Menorrhagia can vary from a dysfunctional aetiology to the existence of pelvic pathology and rarely to systemic disorders.
Apart from the social and psychological effects of Menorrhagia, the severity can be assessed by estimation of the hemoglobin level and other blood indices and the effect on the iron status. Menorrhagia is the commonest cause of iron deficiency anaemia in the reproductive age women.
Cause of Menorrhagia
The causes of Menorrhagia can be categorized into three main groups, namely:
- Dysfunction uterine bleeding (DUB),
- Bleeding due to pelvic pathology,
- Medial disorders including coagulation defects.
DUB is a diagnosis of exclusion.
Systemic disease occasionally causes Menorrhagia. Systemic causes of Menorrhagia can vary from
- Blood dyscresia, leukemia
- Coagulopathy, thrombocytopenic Purpura, severe anemia
- Thyroid dysfunctions, both hypothyroidism and hyperthyroidism
- Early stage of genial tuberculosis
- Von Willebrand’s disease and other blood factor deficiency states
- Autoimmune disorders like idiopathic thrombocytopenia and systemic lupus erythomatosus;
- Use of anticoagulants like warfarin
- Chronic liver disease
- Uterine fibroids
- Endometrial polyps
- Presence of intra-uterine contraceptive device (IUCD)
- Endometrial hyperplasia;
- Rarely, endometrial cancer.
- Poststerlisation menorrhagia
- Progestogen – only pills
Hormonal or dysfunctional
- Irregular shedding of endometrium, irregular ripening of endometrium
- Anovulatory cycles (oestrogen withdrawl)
- Metropathia haemorrhagica
Large submucous fibroids and pedunculated fibroid polyps are associated with the heaviest degree of loss.
Unsuspected pregnancy bleeding can present like an acute episode of Menorrhagia or complicate an ongoing chronic Menorrhagia. Menorrhagia can occur in postmenopausal women taking hormone replacement therapy.
Symptoms of Menorrhagia
The word Menorrhagia means excessive flow of blood during the menstruation. In this condition the menstrual period may be regular as to time, or it may come too early, or it may last too long. Excessive flow of blood produces paleness of face, sunken eyes, and is usually attended with lassitude, a sense of oppression in the head, wandering pains in the lack, loins, and lower extremities: sense of weight and pressure in the pelvis; chilliness, cold feet, weak sight, weak pulse and impaired appetite.
Assessment of Menorrhagia
The number of sanitary towels used, duration of bleeding, or passage of clots has been shown to have little or no correlation with actual blood lost. However, complaints of ‘flooding’ (leakage of heavy blood onto clothes are indicative of heavy menstrual loss. Similarly, severity of bleeding can be assessed by determining the impact it has on the individuals’ quality of life. It is important therefore, to ask about the degree of disability experienced, such as time lost from work, or becoming housebound during menses owing to fear of social embarrassment from an episode of flooding in public.
The patient should also be questioned about symptoms suggestive of anaemia. A history of irregular bleeding, dyspareunia, pelvic pain, inter-menstrual or postcoital bleeding may raise the suspicion of underlying pathology.
A history suggestive of systemic disease such as thyroid disorder or a clotting abnormality would signal that further investigation for such causes would be required. The patient should also be questioned about risk of factors for endometrial cancer such as use of unopposed oestrogen, polycystic ovary syndrome and family history or endometrial or colon cancer. It is also important to establish if the patient has a history of thromboembolism, as many medical treatments for Menorrhagia are hormonal and thus their use may be contraindicated.
Investigations in case of Menorrhagia
Full blood count to exclude anaemia, with iron supplementation offered if required. A hemoglobin estimation is best accompanied by a serum ferritin level to reflect the iron stores.
Pelvic ultrasound may be particularly useful in specific situation and may provide information to support a specific diagnosis. Ultrasound examination is less satisfactory at identifying areas of endometriosis or inflammation accompanied by anatomical distortion from complications. A pelvic ultrasound scan should be performed if history or examination suggests structural uterine pathology, or if it is not possible to assess the uterus clinically because of obesity. The site and size of abnormalities such as fibroids can be determined, together with assessment of the ovaries.
Sampling the endometrium in the surgery can be a useful procedure if a positive result is obtained. If it is negative then a further procedure is indicated. Endometrial sampling via the hysteroscope remains the gold slandered to check the endometrial pathology. Endometrial assessment should be performed in all women > 40 years, or younger women with persistent Menorrhagia, irregular bleeding, or for whom there are risk factors for endometrial cancer. This can take the form of an endometrial biopsy or a hysteroscopy, both of which can be carried out either as an outpatient or inpatient.
A dilatation and curettage is a diagnostic and not a therapeutic test, and should be accompanied by a hysteroscopy. The endometrial pathologies that can be diagnosed by hysteroscopy include:
- Submucous fibroids,
Hysteroscopy will also help in confirming the dysfunctional aetiology of Menorrhagia.
Indications of dilatation and curettage and hysteroscopy in women with menorrhagia
- Women over 40 years of age
- Under 40 years with persistent IMB
- Under 40 years with failed medical treatment
- Abnormal endometrial sample
- Abnormality suggested on transvaginal ultrasound
Thyroid function tests and tests of coagulation should only be performed if there are features suggestive of this in the history. No other endocrine tests are necessary.
A cervical smear should be taken if one is due, or if the cervix looks clinically suspicious.
Homeopathy Treatment of Menorrhagia
Homeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the theory of individualization and symptoms similarity by using holistic approach. This is the only way through which a state of complete health can be regained by removing all the sign and symptoms from which the patient is suffering. The aim of homeopathy is not only to treat menorrhagia but to address its underlying cause and individual susceptibility. As far as therapeutic medication is concerned, several remedies are available to treat menorrhagia that can be selected on the basis of cause, sensations and modalities of the complaints. For individualized remedy selection and treatment, the patient should consult a qualified homeopathic doctor in person. There are following homeopathic remedies which are helpful in the treatment of menorrhagia:
Cimicifuga / Actea racemosa: menses are profuse and too early, sometimes twice a month; blood is dark coagulated; there is bearing down and pressing pains in the uterine region; this pain traverses from hip to hip. Severe pains in lower extremities; backache after menstruation, with heavy pressing down sensation. Shooting and throbbing pains in head as a reflux of uterine bleeding; nausea and vomiting caused by pressure on the spine. Sabina patient is so much depresses that she cries when questioned; sensation as if some weight is laid on her head; almost all the symptoms are due to fear and she is worse during menstrual flow. The mental symptoms are intermingled with rheumatism. Mental symptoms are worse during menses.
Belladonna: Menses too early and profuse. Violent pressing down, as if everything would escape through the genitals. The discharge is bright red, with a sensation of heat. Sometimes it has bad door with lumps. Congestion to the head, throbbing headache and pain in the small of the back.
Calcarea carb.: Menstruation too soon, too profuse and lasting too long. Vertigo when stooping, worse on rising or going upstairs. Feet feel as if they had cold and damp stockings. Preceding the flow, there may be swelling and sensitiveness of the breasts, headache, colic and shivering. During the flow, cutting in the abdomen, toothache, and bearing down. The means are dark colored or black and thick.
China: Menses too profuse with a flow of dark clots. Great distension of abdomen not relieved by eructations or passing of flatus. Frequent desire to urinate; pale urine. Ringing in ears and fainting spells.
Erigeron: it is a very good remedy for hemorrhages of all kinds, but like all homeopathic remedies, it will show effect if prescribed on totality. The hemorrhage of this remedy, immaterial from which orifice it may take place, is cauterized by the bright redness of the discharge. In cases of menorrhagia this bright red bleeding is associated with dysuria (painful urination) and irritation of the rectum.
Ferrum met: Iron is the main component of the human blood and this homeopathic remedy is best adapted to anaemic people. It is either a cachectic state, due to faulty nutrition and assimilation or simple deficiency of blood due to hemorrhages. Menses are too profuse and too long lasting and all through this time, face looks fiery red with ringing in ears. The copiousness of the discharge forbids all movement, as the least movement aggravates the flow. Patient is extremely debilitated.
Ipecac: The principal feature of Ipecac is its persistent nausea and vomiting but it is also a great anti hemorrhagic medicine. Hemorrhages are bright red, profuse and steady in flow. Menorrhagia is accompanied with nausea and characteristic pain from navel to uterus.
Coccus Cacti: Menses too early, profuse, black and thick. Flow only in the evening and at night. Large clots escape when passing urine.
Cyclamen: Menses are profuse, black and membranous. Menses comes early and give certain relief in her mental symptoms. Post partum haemorrahage with severe labour like pain. Irregularities in menses associated with migraine and blindness.
Iodium: Menorrhagia due to endocrine dysfunction ,especially of the thyroid gland; the synthesis of thyroxin is hampered in these patients; menstruation is irregular; uterine hemorrhage; menorrhagia with enlarged and indurated uterus. Iodum may be thought of when hemorrhage is due to pathological condition of uterus; there is acute catarrh of endometrium; great weakness during menses, wedge like pain in right ovarian region; hemorrhage occurring at every stool with cutting pain in the abdomen, pain in the loins and small of back. Patient shows signs of rapid metabolism. Loss of flesh with great appetite. Hot patient, better by cold; patient wants to move all the time as the symptoms are relieved when she is busy.
Phosphorus: Dysfunctional uterine bleeding (DUB) is an important cause of menorrhagia; polycystic ovarian disease may be seen developed if the patient has sycosis as predominant miasm; menses too early and scanty but last too long; stitching pains; women, burning and stitching pain in the region of uterus; ovaries are inflamed and painful at the time of menses; these pains are radiating down the inner side of the thighs; fibroids of the uterus are common; menorrhagia due to uterine polypi.
Sabina: It is a great anti hemorrhagic remedy; Sabina acts upon the mucous membrane of the uterus and also upon the serous membranes; pain flies from sacrum to pubis. hemorrhage is profuse at the time of menses; they are long lasting, partly fluid and partly clotted, offensive in nature; blood comes in gushes; intense colicky pains in abdomen at the time of menses, these pains are associated with bearing down or labor like pains; pain traverse from vagina to uterus; discharge of blood between periods with sexual excitement; inflammation of the tubes, ovaries and uterus; uterine fibroids are usually the cause of menorrhagia at the climacteric age; profuse leucorrhoea and the discharge is bloody.Patient is nervous sad and depressed. music makes her nervous; also music is intolerable for her.
Secale cor.: Menses are too profuse and too long lasting with violent spasms. Discharge dark, liquid blood, increased by motion. All her symptoms are worse just before the menses. Suitable to thin women. Continuous oozing of watery blood until next period.
Nux Vomica: Menses too early and profuse; discharge of dark colored blood. The discharge after continuing for several days, stops and then returns. Cramp like pains in the abdomen, extending down to the thighs. She gets angry and violent without provocation. Habitual constipation, with frequent urging to stool.
Millefolium: Painless hemorrhage is the key symptom of millefolium to be prescribed. Menses early profuse and protracted.
Thalaspi bursa: too copious and too frequent menses usually due to uterine fibroid. Bruised, sore feeling in the back with menses. Every alternate menses is copious.
Trillium pendulm: It has been used with great success in all kind of uterine hemorrhages -anti partum, post partum and climacteric. The characteristic of this hemorrhage is its association with faintness and dizziness. Bleeding aggravates with least motion.
Ustilago maydis: Menorrhagia at menopause; flabby condition of the uterus. Flow is accompanied with sharp pain across the lower abdomen and from hip to hip. In Ustilago the hemorrhage is passive; from retention of remains after miscarriage. The blood that keeps oozing for days and weeks become darkish and coagulated.
Xanthoxylum: menses too early and profuse; menstrual blood is almost black, comes in strings and with clots. It is an excellent remedy for neuralgic dysmenorrhoea; violent agonizing, grinding pain not ameliorated by anything; pain goes to thighs or radiate over whole body.