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Menstruation: Heavy Bleeding (Menorrhagia)

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WHAT IS MENSTRUATION?

The Reproductive System

Reproductive Organs .

The uterus is a pear-shaped organ located between the bladder and lower intestine. It consists of two parts, the body and the cervix.
When a woman is not pregnant the body of the uterus is about the size of a fist, with its walls collapsed and flattened against each other. During pregnancy the walls of the uterus are pushed apart as the fetus grows.
The cervix is the lower third of the uterus. It has a canal opening into the vagina with an opening called the os, which allows menstrual blood to flow out of the uterus into the vagina.
Leading off each side of the body of the uterus are two tubes known as the fallopian tubes . Near the end of each tube is an ovary.
Ovaries are egg-producing organs that hold between 200,000 and 400,000 follicles (from folliculus, meaning "sack" in Latin); these cellular sacks contain the materials needed to produce ripened eggs, or ova.
The inner lining of the uterus is called the endometrium, and during pregnancy it thickens and becomes enriched with blood vessels to house and support the growing fetus. If pregnancy does not occur, the endometrium is shed as part of the menstrual flow. Menstrual flow also consists of blood and mucus from the cervix and vagina.

Reproductive Hormones.

The hypothalamus (an area in the brain) and the pituitary gland regulate the reproductive hormones. The pituitary gland is often referred to as the master gland because of its important role in many vital functions, many of which require hormones. In women, six key hormones serve as chemical messengers that regulate the reproductive system.

The hypothalamus first releases the gonadotropin-releasing hormone (GnRH) .
This chemical, in turn, stimulates the pituitary gland to produce follicle-stimulating hormone (FSH ) and luteinizing hormone (LH) .
Estrogen, progesterone, and testosterone are secreted by the ovaries at the command of FSH and LH and complete the hormonal group necessary for reproductive health.

Reproductive Processes Leading to Menstruation

The menstrual cycle reflects the changes that occur in the endometrium, the inner lining of the uterus. Layers of the endometrium are shed at the end of the cycle as part of menstrual flow. The menstrual cycle is generally divided into phases:

the follicular phase,
ovulation, and
the luteal (or secretory) phase.

For a clear picture of the process it is important to understand how to count days in a menstrual cycle. Day one is generally considered to be the first day of bleeding.

Follicular Phase . The follicular phase includes menstrual bleeding followed by proliferation (growth and thickening) of the endometrium. It usually lasts from day one to day 14. The following processes occur during this time:

The menstrual flow itself lasts an average of six days. Estrogen and progesterone levels are at their lowest during this time.
At the end of the menstrual flow, the proliferative phase begins, and the endometrium starts to grow and thicken. FSH levels rise and stimulate several ovarian follicles to mature over a two-week period until their eggs nearly triple in size. During this period, FSH also signals the ovaries to produce estrogen, which, in turn, stimulates a great surge of LH around day 14.

Ovulation. The surge of LH at the end of the follicular phase triggers ovulation by causing the largest follicle to burst and release its egg into one of the two fallopian tubes. At ovulation (usually day 14 in a 28-day cycle), the proliferative stage ends and the luteal (secretory) phase begins.

Luteal (Secretory) Phase or Premenstrual Period. The luteal (secretory) phase lasts about 14 days. This is also commonly known as the premenstrual period . The following processes occur during this time:

Once ovulation has occurred, LH causes the ruptured follicle to develop into the corpus luteum, a mound of yellow tissue that produces progesterone.
Acting together, progesterone and estrogen stimulate the tissue lining the uterus to prepare a thick blanket of blood vessels where a fertilized egg can attach and develop. If an egg is fertilized, this blood-vessel blanket supplies nutrients for the developing pregnancy.
The corpus luteum continues to produce progesterone and estrogen.
When fertilization does not occur, the corpus luteum degenerates to a form called the corpus albicans (Latin for "white body"), and estrogen and progesterone levels drop.
Finally, the endometrial lining sloughs off and is shed during menstruation.

Typical Menstrual Cycle

Menstrual Phases	Typical No. of Days	Hormonal Actions
Follicular (Proliferative) Phase	Days 1 through 6: Beginning of menstruation to end of blood flow.	Estrogen and progesterone start out at their lowest levels. FSH levels rise to stimulate maturity of follicles. Ovaries start producing estrogen and levels rise, while progesterone remains low.
	Days 7 - 13: The endometrium (the inner portion or lining of the uterus) thickens to prepare for the egg implantation.
Ovulation	Day 14:	Surge in LH. Largest follicle bursts and releases egg into fallopian tube.
Luteal (Secretory) Phase, also known as the Premenstrual Phase	Days 15 – 28:	Ruptured follicle develops into corpus luteum, which produces progesterone. Progesterone and estrogen stimulate blanket of blood vessels to prepare for egg implantation.
	...If fertilization occurs:	Fertilized egg attaches to blanket of blood vessels which supplies nutrients for the developing pregnancy. Corpus luteum continues to produce estrogen and progesterone.
	...If fertilization does not occur:	Corpus luteum deteriorates. Estrogen and progesterone levels drop. The blood vessel lining sloughs off and menstruation begins.

Stages and Features of Menstruation

Onset of Menstruation (Menarche). The onset of menstruation, called the menarche, usually occurs at age 12 or 13. One study, however, has indicated that girls may be starting puberty earlier than in the past. By the age of eight, 48% of African-American girls and 15% of white girls were showing pubic hair and developing breast buds. It had previously been thought that only 1% of girls exhibited such changes at that age. Alternatively, a study done in England found that the average age for the onset of menstruation has changed very little since the 1950s, with the median age being 13 years.

Researchers are looking for reasons for this trend toward earlier menstruation. Being overweight is a risk factor for early puberty, and the increasing incidence of childhood obesity in the US may play a role. Some experts believe, however, that environmental estrogens found in chemicals and pesticides are major suspects. (Of concern in this regard are hair products that contain estrogens, which are being used by some young girls.)

Length of Monthly Cycle. The menstrual cycle can be very irregular for the first one or two years, usually being longer than the average of 28 days. It then typically stabilizes to 28 days until a woman reaches her 40s when the cycle lengthens, reaching an average of 31 days by age 49. A number of other factors can also affect cycle length. [ See Table .] In fact, the cycle may range from 20 to 40 days and still be considered normal, but a variation of 10 days or more, either more or fewer days, may have an impact on fertility.

Risk Factors for Shorter Cycles	Risk Factors for Longer Cycles
Regular alcohol use.	Being under 21 and over 44.
Stressful jobs.	Being very thin (also at risk for short bleeding periods).
	Competitive athletics (also at risk for short bleeding periods).
	Lower socioeconomic groups.

Length of Periods. Periods average 6.6 days in young girls. By the age of 21, menstrual bleeding averages six days until women approach menopause. It should be noted, however, that about 5% of healthy women menstruate less than four days and 5% menstruate more than eight days. Thin women, particularly those who smoke, tend to have longer bleeding periods, while athletes tend to have shorter ones. Women who use oral or injected contraceptives generally have shorter periods.

Normal Absence of Menstruation. Normal absence of periods can occur in any woman under the following circumstances:

Menstruation stops during the duration of pregnancy. Some women continue to have irregular bleeding during the first trimester. This bleeding may indicate a threatened miscarriage and requires immediate attention by the physician.
When women breast feed they are unlikely to ovulate during the first eight weeks after delivery. After that time, menstruation usually resumes and they are fertile again.
Perimenopause starts when the intervals between periods begin to lengthen, and it ends with menopause itself (the complete cessation of menstruation). Menopause usually occurs at about age 51, although smokers often go through menopause earlier.

WHAT IS MENORRHAGIA (HEAVY MENSTRUAL BLEEDING) AND OTHER MENSTRUAL DISORDERS?

Menorrhagia (Heavy Bleeding)

During normal menstruation the average woman loses about 2 ounces (60 ml) of blood or less. If bleeding is significantly heavier, it is called menorrhagia, which occurs in 9% to 14% of all women and can be caused by a number of factors. Women often over estimate the amount of blood lost during their periods. However, women should consult their physician if one or both of the following occurs:

Regularly changing pads or tampons more frequently than every hour or so. (Clot formation is fairly common during heavy bleeding and is not a cause for concern.)
Periods regularly last more than eight to ten days.

Bleeding between periods or during pregnancy also warrants a visit to the doctor. (Spotting or light bleeding between periods is common in girls just starting menstruation and sometimes during ovulation in young adult women, but consultation with a physician is nevertheless recommended.)

Other Menstrual Disorders

Amenorrhea (Absence of Menstruation). Amenorrhea is the absence of menstruation. There are two categories: primary amenorrhea and secondary amenorrhea. Such terms are used only to describe the timing of menstrual cessation; they do not indicate any cause nor do they suggest any other information.

Primary amenorrhea occurs when a girl does not even start to menstruate. Girls who show no signs of sexual development (breast development and pubic hair) by age 14 should be evaluated. Girls who do not have their periods by two years after sexual development should also be checked. Any girl who does not have her period by age 16 should be evaluated for primary amenorrhea.
Secondary amenorrhea occurs when periods that were previously regular become absent for at least three cycles. [For more details, see the Report # 101, Amenorrhea.]

Oligomenorrhea (Light or Infrequent Menstruation). Oligomenorrhea is a condition in which menstrual cycles are infrequent. It is very common in early puberty and not usually worrisome. When girls first menstruate they often do not have regular cycles for a couple of years. Even healthy cycles in adult women can vary by a few days from month to month. In some women, periods may occur every three weeks and in others, every five weeks. Flow also varies and can be heavy or light. Skipping a period and then having a heavy flow may occur; this is most likely due to missed ovulation rather than a miscarriage. Women should be concerned when periods come less than 21 days or more than 2 to 3 months apart, or if they last more than eight to ten days. Such events may indicate ovulation problems.

Dysmenorrhea (Severe Menstrual Cramps). Uterine contractions occur during all periods, but in some women these cramps can be frequent and very intense. In such cases the condition is known as dysmenorrhea. It can be primary or secondary.

Primary dysmenorrhea is caused by normal uterine muscle contractions and affects more than half of menstruating women. It usually starts two to three years after the periods have started. The pain usually develops when the bleeding starts and continues for 32 to 48 hours.
Secondary dysmenorrhea is menstrually related pain that is caused by other medical conditions, usually endometriosis or pelvic abnormalities. [For more Information see the Report #100, Dysmenorrhea.]

Up to 80% of all women report some symptoms related to fluctuating hormone levels as menstruation approaches. For about half of these women, symptoms are mild and do not affect normal daily life. The other half report symptoms severe enough to impair daily life and relationships.

Premenstrual Syndrome. In general premenstrual syndrome (PMS) is a set of physical, emotional, and behavioral symptoms that occur during the last week of the luteal phase (a week before menstruation) in most cycles. The symptoms should typically resolve within four days after bleeding starts and not start until at least day 13 in the cycle. Women may begin to experience premenstrual syndrome symptoms at any time during their reproductive years. Once established, the symptoms tend to remain fairly constant until menopause, although they can vary from cycle to cycle. About 100 symptoms have been identified with the premenstrual phase. [For more details, see Report #79, Premenstrual Syndrome .]

WHAT CAUSES HEAVY MENSTRUAL BLEEDING AND WHO IS AT RISK?

Almost all women, at some time in their reproductive life, experience heavy bleeding during a period. It should be noted, however, that while 30% of premenopausal women complain of heavy bleeding, only 10% experience blood loss severe enough to be defined as menorrhagia. Many women, in fact, complain of heavy menstrual bleeding but their bleeding is actually normal. (On the other hand, some women with a family history of bleeding disorders might have menorrhagia but think it is normal.) During normal menstruation women lose about 2 ounces (60 ml) of blood or less.

Factors Associated with a Higher Risk for Heavy Menstrual Bleeding

The following characteristics are associated with a higher risk for menorrhagia:

Being taller.
Being older. (Women who have late periods or are approaching menopause may experience occasional menorrhagia.)
Having a higher number of pregnancies.

Specific Conditions that Cause Heavy Menstrual Bleeding

A number of conditions are known to contribute to menorrhagia, including the following:

Fibroids. [For more information, see the Report Fibroids: Uterine.]
Uterine polyps. (These are small benign growths in the uterus.)
A retroverted uterus (so-called tipped uterus).
Certain contraceptives. (Oral contraceptives or an intrauterine device, an IUD.)
An isolated instance of heavy bleeding may be due to a miscarriage. If the bleeding occurs at the usual time of menstruation, however, miscarriage is less likely to be a cause.
Bleeding disorders. Bleeding disorders that impair blood clotting can cause heavy menstrual bleeding and, according to different studies, have been associated with between 10% and 17% of menorrhagia cases. Von Willebrand disease, a genetic condition, is the most common of these bleeding disorders. Most, but not all studies, report this problem to be more common in African American than Caucasian women. Other rare disorders that impair blood platelets and clotting factors can also account for some cases of menorrhagia. Most bleeding disorders have a genetic basis and should be suspected in adolescent girls who experience heavy bleeding.
Uterine cancer.
Pelvic infections.
Endometriosis. (These are small implants of uterine tissue. They are more likely to cause pain than bleeding.)
Adenomyosis. This condition occurs when glands from the uterine lining become embedded in the uterine muscle, causing heavy bleeding and also pain. It is most likely to develop in middle-aged women who have had many children.
A number of medical conditions: thyroid problems, systemic lupus erythematosus, diabetes, certain cancers and chemotherapies, and some uncommon blood disorder.
Certain drugs, including anticoagulants and anti-inflammatory medications, can also cause heavy bleeding.

Biologic Factors Implicated in Heavy Bleeding

In some cases the cause of heavy bleeding is unknown, and basic physiologic factors may be responsible, although their mechanisms are not fully clear.

Hormone Imbalance. If estrogen and progesterone imbalances cause one or more periods to be skipped, overgrowth of the endometrial lining can occur, so that when a period finally occurs, menstruation can be very heavy.

Factors that Affect Opening and Narrowing of Blood Vessels . Elevated levels of compounds called endothelins and nitric oxide may contribute to heavy menstrual bleeding. Endothelins are powerful dilators (openers) of blood vessels. They appear to interact with nitric oxide, a substance that relaxes the smooth muscles that line blood vessels. A 1999 study reported higher production of nitric oxide in the uterine linings of women who suffer from menorrhagia than those who don't. Some experts believe it plays a large role in heavy bleeding.

Prostaglandins. Prostaglandins are factors that are released by the immune system. They cause blood vessels to open and enhance uterine contractions.

Angiogenesis. Angiogenesis is the production of new blood vessels and is an important process for the repair and growth of the uterine lining during a woman's reproductive life. Some research suggests that imbalances in certain immune factors and growth hormones can affect angiogenesis and may be responsible for some cases of menorrhagia.

HOW SERIOUS IS HEAVY MENSTRUAL BLEEDING?

An estimated 10% of all women in their reproductive years have chronic gynecologic problems. Nearly 30% of women reporting such problems spend one or more days in bed per year because of them.

Anemia

Menorrhagia is the most common cause of anemia in premenopausal women. According to one report, 10% of women in their reproductive years have iron deficiencies, and between 2% and 5% have iron levels low enough to cause anemia. Although poor diets play a role in many cases, the problem is compounded in women who have heavy periods. A 2001 study further reported that women with a history of taking nonsteroidal anti-inflammatory drugs (NSAIDs) and antacids have a higher risk for anemia. NSAIDs are agents sometimes used to reduce menstrual pain or heavy bleeding.

Most cases of anemia are mild, but even mild anemia can cause weakness and fatigue. Moderate to severe anemia can also cause shortness of breath, rapid heart rate, lightheadedness, headaches, ringing in the ears (tinnitus), irritability, pale skin, restless legs syndrome, and mental confusion. Heart problems can occur in prolonged and severe anemia that is not treated. Pregnant women who are anemic, particularly in the first trimester, have an increased risk for a poor pregnancy outcome.

Pain Severity

Heavy bleeding is often accompanied by menstrual cramps. In one English study of nurses, the incidence of menstrual pain was high. Most of these women reported, however, that, although the pain was bothersome, they generally treated their own pain and few sought medical help. Two thirds of those who did see their general practitioners were dissatisfied with the treatment offered. [For more information see the Report #100, Dysmenorrhea .]

Infertility

Many conditions associated with menstrual irregularities, including heavy bleeding, such as ovulation abnormalities, fibroids, and endometriosis, are major contributors to infertility. Irregular periods from any cause make it more difficult to conceive.

Toxic Shock Syndrome and Infection

Women with heavy periods may use two tampons at a time and are at risk for pushing one in so far that it becomes impossible to retrieve without professional assistance. Keeping tampons in for more than six hours increases the risk for infection. Of particular concern is toxic shock syndrome (TSS), a potentially life-threatening condition caused by bacteria that adhere to tampons and begin producing toxins. Symptoms include very high fever, diarrhea, sore throat, and extreme weakness. A peeling rash may develop, usually on the hands and feet. Blood pressure drops to dangerous levels. TSS now occurs rarely since super-absorbent tampons were withdrawn from the market.

WHAT ARE THE DIAGNOSTIC PROCEDURES FOR HEAVY MENSTRUAL BLEEDING?

It is often very difficult to diagnose true menorrhagia. For one, it is very difficult to measure blood loss during menstruation, and the perceptions of women as well as their physicians vary widely.

Some women may overestimate their menstrual flow. In one study 29% of women reporting menorrhagia had normal menstrual blood flow (less than about 2 ounces or 60 ml). In the study, such women tended to be anxious, unemployed, and also to have abdominal pain.
Some women underestimate it. For example, women with a family history of bleeding disorders might have menorrhagia but think it is normal because it is the same as their mother's or sister's.
Physicians may underestimate their patient's flow. In one study, comparing the perception of menstrual flow between physicians and patients, physicians believed that only 3.2% of their patients had menorrhagia while 53.7% of these patients self-reported the condition using an objective pictorial self-assessment chart.

Pelvic Examination

A physician will perform a pelvic examination to check for pregnancy-related conditions or any abnormalities, such as ovarian cysts or fibroids.

Pictorial Assessment Chart

The use of a pictorial assessment chart is proving to be a very accurate method for self-reporting menstrual blood loss.

Medical and Personal History

The physician needs to have a complete history of any medical or personal conditions that might be causing heavy bleeding. He or she may need the following information:

Any family history of menstrual problems or bleeding disorders (which should be suspected in teenage girls with heavy bleeding). It should be noted that, in some cases, young women with heavy bleeding from inherited conditions may not even report it if they grew up in a family where such bleeding was considered normal.
The presence or history of any medical conditions that might be causing heavy bleeding. Women who visit their gynecologist with menstrual complaints, particularly heavy bleeding, pelvic pain, or both may actually have an underlying medical disorder, which must be ruled out. [ See What Causes Heavy Menstrual bleeding and Who is at Risk? .]
The pattern of the menstrual bleeding. (If it occurs during regular menstruation, nonhormonal treatments are tried first. If it is irregular, occurs between periods, occurs after sex, is associated with pelvic pain, or if it occurs with premenstrual pain, the physician should look for specific conditions that may cause these problems.)
Regular use of any medications (including vitamins and over-the-counter agents).
Diet history, including caffeine and alcohol intake.
Past or present contraceptive use.
Any recent stressful events.
Sexual history. (It is very important that the patient trust the physician enough to describe any sexual activity that might be risky.)

Hysteroscopy

Hysteroscopy is a procedure that may be used to detect the presence of fibroids, polyps, or other causes of bleeding. (It may miss cases of uterine cancer, however, and is not a substitute for more invasive procedures, such as D&C or endometrial biopsy, if cancer is suspected.) The procedure uses a fiber optic light source inside a long flexible or rigid tube, which is inserted into the uterus in order to view the cavity. The image of the uterine cavity is transmitted by camera lenses to a video screen. Hysteroscopy is non-invasive, but 30% of women report severe pain with the procedure. One study suggested that the use of an anesthetic spray such as lidocaine may be highly effective in preventing pain from this procedure.

Imaging Techniques

Ultrasound and Sonohysterography. Ultrasound is the standard imaging technique for evaluating the uterus and ovaries, detecting fibroids, ovarian cysts and tumors, and also obstructions in the urinary tract. It uses sound waves to produce an image of the organs and entails no risk and very little discomfort.

Transvaginal sonohysterography uses ultrasound along with saline infused into the uterus, which enhances the visualization of the uterus. This technique is proving to be more accurate than standard ultrasound in identifying potential problems. Some experts believe it should become a first line diagnostic tool for diagnosing heavy bleeding.

Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) gives a better image of any fibroids that might be causing bleeding, but it is expensive and not usually necessary.

Endometrial Biopsy with or without Dilation and Curettage (D&C)

When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy can be performed in the office along with an ultrasound. It is usually used with a procedure called dilation and curettage (D&C), which is particularly important to rule out uterine (endometrial) cancer. A D&C is a somewhat invasive procedure:

A D&C is usually done in an outpatient setting so that the patient can return home the same day, but it sometimes requires a general anesthetic. It may need to be performed in the operating room to rule out serious conditions or treat some minor ones that may be causing the bleeding.
The cervix (the neck of the uterus) is dilated (opened).
The surgeon scrapes the inside lining of the uterus and cervix.

The procedure is used to take samples of the tissue and to relieve heavy bleeding in some instances. D&C can also be effective in scraping off small endometrial polyps, but it is not very useful for most fibroids, which tend to be larger and more firmly attached.

Blood Tests

Tests for bleeding disorders are important, particularly in very young women, before proceeding with invasive tests. Certainly blood testing for anemia is an important consideration in determining the need and type of treatment.

WHAT ARE THE HOME REMEDIES FOR MENSTRUAL SYMPTOMS AND HEAVY MENSTRUAL BLEEDING?

Dietary Recommendations for Preventing Menstrual Cramps and Other Symptoms

Making dietary adjustments starting about 14 days before a period may help some women with premenstrual syndrome and certain mild menstrual disorders, such as cramping, which commonly accompanies heavy bleeding. The general guidelines for a healthy diet apply to everyone:

Eat plenty of whole grains, fresh fruits and vegetables.
Avoid saturated fats and commercial junk foods.

Low-Fat, High-Fish Diets. A 2000 study reported that women who followed a low-fat vegetarian diet for two menstrual cycles experienced less pain and bloating and a shorter duration of premenstrual symptoms than those who ate meat. Women who are losing too much blood, however, may need meat to help maintain iron levels. Choosing more fish and eggs may be a helpful alternative. More than one study has reported less menstrual pain with a higher intake of omega 3 fatty acids (fat compounds found in oily fish, such as salmon and tuna). In another, supplements of fish oil appeared to reduce heavy bleeding in adolescent girls.

Salt Restriction. Limiting salt may help bloating. One study found that restricting salt does not alleviate bloating or other symptoms, but salt reduction in the study was modest and may have been too small to effect improvement.

Reducing Caffeine, Sugar, and Alcohol. Reducing caffeine, sugar, and alcohol intake may be beneficial. The effects of alcohol are mixed. One study found that women who drank less wine had less menstrual pain than those who drank more wine. Another reported that regular consumption of alcohol lowered the risk for developing cramps, but it actually increased the length of cramping time in certain women. Alcohol is certainly not recommended in any case for relieving menstrual disorders.

Menstrual Hygiene

Tampons should be changed every four to six hours. Scented pads and tampons should be avoided; feminine deodorants can irritate the genital area. Women should not douche during or between periods. Women who douche on a weekly basis are more likely to contract cervical cancer than those who don't. Douching may destroy the natural anti-viral and anti-bacterial agents normally present in the vagina. Bathing regularly is sufficient.

HOW CAN A WOMAN PREVENT IRON-DEFICIENCY ANEMIA FROM HEAVY MENSTRUAL BLEEDING?

Dietary Recommendations for Preventing Anemia

Foods for Maintaining Healthy Iron Stores. Anyone with low iron stores should be sure to eat foods that are either rich in iron or aid in iron absorption.

The best foods for increasing or maintaining healthy iron levels contain absorbable iron, called heme iron . Such foods include (in order of iron-richness) clams, oysters, organ meats, beef, pork, poultry, and fish.
About 60% of iron in meat is poorly absorbed; this is a form called non-heme iron . Eggs, dairy products, and vegetables that contain iron only have the non-heme form. Such plants include dried beans and peas, iron-fortified cereals, bread, and pasta products, dark green leafy vegetables (chard, spinach, mustard greens, kale), dried fruits, nuts, and seeds. (One study reported that even though non-heme iron is normally less easily absorbed, people who were iron deficient absorbed 10 times the amount of non-heme iron as people with normal iron levels.)
Increasing intake of vitamin-C rich foods can enhance absorption of non-heme iron. Foods that contain vitamin C include, but are not limited to, broccoli, cabbage, citrus fruits, melon, tomatoes, and strawberries. One orange or six ounces of orange juice can double the amount of iron your body absorbs from plant foods.
Foods containing riboflavin (vitamin B2) may help enhance the response of hemoglobin to iron. Sources include liver, dried fortified cereals, and yogurt.
Cooking in cast iron pans and skillets is well known to increase the iron content of food. According to one study, however, boiling, steaming, or stir-frying many vegetables in utensils composed of any material significantly increases the release of iron stored in plants so it is available to the body.

Certain nutrients, such as tannin (found in tea) or phytic acid (found in foods such as seeds and bran) impedes the body's absorption of dietary iron. (It is commonly believed that fiber impeded iron absorption, but researchers report that it most likely has no effect.)

Sources of Vitamins B12 and Folate. Vitamins B12 and folate are important for prevention of anemia and good health in general, particularly in women.

The only natural dietary sources of B12 are animal products, such as meats, dairy products, eggs, and fish (clams and oily fish are very high in B12); like other B vitamins, however, B12 is added to commercial dried cereals. The recommended daily allowance (RDA) is 2.4 mcg a day. Deficiencies are rare in young people, although the elderly may have trouble absorbing natural vitamin B12 and require synthetic forms from supplements and fortified foods.
Folate is best found in avocado, bananas, orange juice, cold cereal, asparagus, fruits, green, leafy vegetables, dried beans and peas, and yeast. The synthetic form, folic acid, is now added to commercial grain products. Vitamins are usually made from folic acid, which is about twice as potent as folate. Many experts now recommend that adults have 400 mcg of folic acid daily, which is considerably higher than standard recommendations of 400 mcg of folate, which does not take into consideration the possible benefits of folate on the heart. Low levels of folate during pregnancy are common without supplements; deficiencies at that time increase the risk of neural tube defects in newborns. Women who are planning to be pregnant should take 400 mcg of folic acid before conception as well as when they are pregnant or breast feeding.

Iron Supplements

Iron supplements are the most effect agents for restoring iron levels but they should be used only when dietary measures have failed. It should be noted that they will not correct anemias that are not due to iron deficiency. One study reported that physicians prescribed iron pills for 64% of patients with anemia without performing tests to confirm whether iron deficiency was actually the cause. The study suggested that iron replacement was appropriate in less than half of these patients. Iron replacement therapy can cause gastrointestinal problems, sometimes severe ones. Excess iron may also contribute to heart disease, diabetes, and certain cancers. No one should take iron supplements if they have a healthy diet and no indications of iron deficiency anemia.

Supplement Forms. To replace iron, the preferred form of iron tablets are ferrous salts, usually ferrous sulfate (Feosol, Fer-In-Sol, Mol-Iron). Other forms include ferrous fumarate (Femiron, FerroSequels, Feostat, Fumerin, Hemocyte, Ircon), ferrous gluconate (Fergon, Ferralet, Simron), polysaccharide-iron complex (Niferex, Nu-Iron), and carbonyl iron (Elemental Iron, Feosol Caplet, Ferra-Cap). Specific brands and forms may have certain advantages. The following are some examples:

Prolonged-release ferrous sulfate (Slow Fe) may enhance iron absorption with fewer side effects than standard ferrous sulfate pills.
FerroSequels contains a stool softener, which helps prevent constipation.
Polysaccharide-iron complex has fewer side effects than and has equal absorption rates to ferrous salts. It is very expensive, however.
Carbonyl iron is composed of very fine tiny uniform spheres of iron powder and may prove to be less toxic than ferrous iron.
Coated or combination pills do not appear to offer any additional advantages and may hinder absorption of the iron.

Regimen. The general guidelines for iron replacement are as follows:

For adults, physicians usually advise one ferrous sulfate tablet (300 mg) three times a day.
Iron replacement doses for children with deficiencies are significantly lower. One study even suggested that children with iron deficiency anemia may do as well taking iron supplements only three days a week instead of daily. As few as three adult iron tablets can poison children, even fatally. This includes any form of iron pill.

No one, even adults, should take a double dose of iron if one is missed.

Other tips for taking iron are as follows:

For best absorption, iron should be taken between meals. (Iron may cause stomach and intestinal disturbances, however, and some experts believe that low doses of ferrous sulfate can be taken with food and absorbed without side effects.)
One should always drink a full eight ounces of fluid with an iron pill.
Tablets should be kept in a cool place. (Bathroom medicine cabinets may be too warm and humid, which may cause the pills to disintegrate.)
One study suggested that iron supplements impeded the absorption of non-heme iron (found in legumes and other vegetables) but not heme iron (contained in meat).

Full recovery takes six to eight weeks. (Recovery will take longer in people with internal bleeding that is not under control.) Iron replacement therapy must continue for about six months, even if anemia has been reversed. Treatment must be continued indefinitely for people with chronic bleeding; in such cases, iron levels should be closely monitored.

Side Effects. Common side effects of iron supplements include the following:

Constipation and diarrhea are very common. They are rarely severe, although iron tablets can aggravate existing gastrointestinal problems such as ulcers and ulcerative colitis.
Nausea and vomiting may occur with high doses, but can be controlled by taking smaller amounts. Switching to ferrous gluconate may help some people with severe gastrointestinal problems.
Black stools are normal when taking iron tablets. In fact, if they do not turn black, the tablets may not be working effectively. This tends to be a more common problem with coated or long-acting iron tablets.
If the stools are tarry looking as well as black, if they have red streaks, or if cramps, sharp pains, or soreness in the stomach occur, gastrointestinal bleeding may be causing the iron deficiency and the patient should call the physician promptly.
Acute iron poisoning is rare in adults but can be fatal in children who take adult-strength tablets.

Interactions with Other Drugs. Certain medications, including antacids, can reduce iron absorption. Iron tablets may also reduce the effectiveness of other drugs, including the antibiotics tetracycline, penicillamine, and ciprofloxacin and the anti-Parkinson's Disease drugs methyldopa, levodopa, and carbidopa. At least two hours should elapse between doses of these drugs and iron supplements.

Supplementary Agents. Adding either ascorbic acid (vitamin C) or succinic acid to ferrous sulfate therapy will improve absorption of iron stores. Ascorbic acid added to iron therapy, however, may exacerbate some of the side effects. Succinic acid added to ferrous sulfate does not appear to increase side effects. Some studies have found that the addition of zinc to iron supplements increases hemoglobin levels more than iron alone. One study of pregnant women suggested that zinc affects a hormone called insulin-like growth factor-I (IGF-I), which plays a role in the regulation of red blood cell production.

WHAT ARE THE DRUG TREATMENTS FOR HEAVY MENSTRUAL BLEEDING?

General Guidelines

Drug therapy can be very useful for many women with menorrhagia. It should be strongly noted that up to half of women who report heavy bleeding do not actually lose abnormal amounts of blood. A correct diagnosis of true menorrhagia is very important, since the treatments, both medications and surgery, can have severe side effects. Women should feel confident that they understand all of their options and exercise their own treatment preferences. A general drug treatment regimen for menorrhagia is as follows:

Nonhormonal Agents. The use of nonhormonal agents are appropriate first choices when the menstrual cycle is regular.

The first options are nonsteroidal anti-inflammatory drugs, with reported reductions in menstrual blood loss of 25% to 35%.
Tranexamic acid is a drug that enhances blood clotting and is used more in Europe than in the US. It is proving to be very effective, and women might ask their physician if it is available.

Hormonal Agents. Hormonal agents are useful for women with heavy bleeding who also want to control the menstrual cycle.

The best choice for women who want effective birth control is either the combined oral contraceptive pill or a progestin containing intrauterine device (Progestasert or Mirena), which reduces bleeding by 50% to 80%. (Progestin-only pills are useful but only when taken at high doses for three weeks out of four.)
Danazol and the gonadotrophin-releasing hormone analogues are highly effective for more severe cases, but their side effects make them suitable only for short-term use.

Nonhormonal Agents

Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins (the substances that increase uterine contractions). They also have other properties that act against inflammatory factors that may be responsible for heavy menstrual bleeding. Aspirin is the most common NSAID, but there are dozens of others available over the counter or by prescription. Among the most effective NSAIDs for menstrual disorders are ibuprofen (Advil, Motrin, Midol PMS), naproxen (Aleve, Naprosyn, Naprelan, Anaprox), and mefenamic acid (Ponstel). Mefenamic acid has been intensively studied and has been shown to reduce bleeding by 30% to 50%. In one major 2000 analysis, however, naproxen was just as effective. In the same study, NSAIDs were equally or more effective than oral contraceptives or progestins. (They weren't as effective as tranexamic acid or danazol.) For maximum benefit, they should be taken seven to 10 days before a period is expected.

It should be noted, however, that long-term use of any NSAID, can increase the risk for gastrointestinal bleeding and ulcers. In fact, one 2001 study of women with iron deficiency anemia reported that overuse of NSAIDs for menstrual disorders contributed to the anemia.

COX-2 Inhibitors. Celecoxib (Celebrex), rofecoxib (Vioxx), and meloxicam (Mobic) are known as COX-2 (cyclooxygenase-2) inhibitors, the so-called super-aspirins. Standard NSAIDs block two prostaglandin-producing enzymes called cyclooxygenase 1 and 2 (COX-1 and 2). The new drugs block COX-2 (responsible for most inflammatory effects) but not COX-1, which normally protects the stomach. Short-term studies comparing them to a number of NSAIDs are indicating that they may be as effective and less harmful to the GI tract than NSAIDs.

Tranexamic Acid. Tranexamic acid (available in the UK as Cyclokapron) is a synthetic form of the amino acid lysine and enhances blood clotting. In a major 2000 analysis, it was more effective in reducing blood flow than oral progestins or the NSAID mefenamic acid. Women also reported a better quality of life with tranexamic acid than with the progestin. Side effects may include headache and nausea. There is some concern that it may increase the risk for blood clots, but a long-term Swedish study reported that it posed no higher than average risk for blood clots. (Nevertheless, women with any risk factors for blood clots should not use this agent.) Tranexamic acid is currently recommended in the US only when fibroids, endometriosis, or other uterine lesions have been ruled out, and when oral contraceptives are ineffective.

Hormonal Therapies

Combination Oral Contraceptives. Oral contraceptives (OCs), commonly known collectively as "the Pill," contain combinations of an estrogen and a progestin (either a natural progesterone or the synthetic form called progestogen). These agents block production of male hormones and inhibit receptors for estrogen in the uterus. OCs are often used to regulate periods in women with menstrual disorders, including menorrhagia (heavy bleeding), dysmenorrhea (severe pain), and amenorrhea (absence of periods). They also protect against ovarian and endometrial cancers . It is not clear, however, if they are any more effective than NSAIDs in reducing heaving bleeding, but they may still be a good option for women seeking both birth control and relief from menorrhagia.

Estrogen and progestin each cause different side effects. [See Box Side Effects of Hormonal Contraceptives.]

Uncommon but more dangerous complications of OCs include high blood pressure and deep-vein blood clots (thrombosis), which may contribute to heart attacks or strokes. It should be noted that a long-term study of 46,000 British women found no difference in mortality rates between women who took OCs and those who did not. The most serious side effects are due to the estrogen in the combined pill. Women at risk can usually take progestin-only OCs.

Blood Clots (Thrombosis). Oral contraceptive use increases the risk for blood clots, particularly in women with inherited clotting defects. The risk is highest in the first few months. Whether the newer generation progestins desogestrel and gestodene pose a higher risk for blood clots than those containing levonorgestrel is unclear. If they do, it is very slight, particularly in women with no other risk factors.
Stroke. Evidence consistently suggests a higher than normal risk for stroke in women taking OCs, even at current low estrogen dosages and even if women have no other stroke risk factors, such as migraine, high blood pressure, and smoking. (Low dosages pose a lower risk than high doses, however.) Even so, absolute risk for a stroke is still extremely low, and low-dose OCs would add only 4.1 strokes per 100,000 women who have no other risk factors for stroke. Smoking, migraines, and high blood pressure add considerably to the risk.
High Blood Pressure. High blood pressure that occurs after a woman begins taking OCs can usually be corrected by discontinuing the medication, and women who use OCs should not be unduly alarmed. Of some concern was a study suggesting that OCs may cause a small but persistent increase in diastolic blood pressure (the second number in a blood pressure reading), which in turn may increase the risk for heart disease years later.
Heart Attacks. Smoking and high blood pressure may also increase the risk for heart attacks in women taking OCs.

Progestins. Progestins (either natural progesterone or synthetic progestogen) are used by women with menorrhagia to restore regular cycles. A number of forms are available and have specific advantages and disadvantages. [ See Box Side Effects of Hormonal Contraceptives.]

Oral synthetic progestins include medroxyprogesterone (Provera, Amen, Curretab, Cycrin, Depo-Provera), norethindrone acetate (Aygestin, Norlutate), and norgestrel (Ovral). In some cases, oral progestins are taken during the luteal phase (the premenstrual phase), but this treatment is no more effective in reducing bleeding than NSAIDs. They are more useful when taken for 21 days each cycle, but they have unpleasant psychological and physical side effects such as depression, moodiness, and bleeding.
Natural progestins (called progesterone) may be helpful. A natural oral form of finely ground (micronized) progesterone (Prometrium), which is made from wild yams, is also available and has fewer side effects. Crinone, another natural progesterone, is applied as a sustained-release gel in the vagina. The application allows progesterone to go directly from the vagina to the uterus and, when a woman also takes estrogen, the combination simulates the natural luteal phase of the menstrual cycle. There are few side effects.
An advanced version of the progestin-releasing intrauterine device (IUD) called the levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena), releases progestin for up to seven years. Studies are reporting significant reduction in blood loss with its use. Side effects include nausea and bloating, but progestin released by the IUD mainly effects the uterus and cervix and so causes fewer widespread side effects than the progestin pills do. It is proving to be a good alternative to hysterectomy for many women. Irregular break-through bleeding can occur for the first six months, but afterward 80% to 90% reduction in blood loss has been reported. It should be noted, however, that some women experience recurrence of menorrhagia and may need surgical procedures.

Side Effects of Hormonal Contraceptives

Estrogen and progestin each cause different side effects.

During the first two or three months of use, side effects from estrogen in the combined pill include:

Nausea and vomiting. (Can often be controlled by taking the pill during a meal or at bedtime.)
Headaches.
Dizziness.
Breast tenderness and enlargement.
Weight gain.

Most of the adverse effects of progestins, alone or in combinations, are due to the fact that they act like male hormones. Such side effects include the following:

Spotting and bleeding between periods (break-through bleeding). Progestin thins the lining of the uterus and prevents it from shedding. Because of this, menstrual disorders such as spotting between periods, longer or heavier periods, or no periods at all (amenorrhea) are common side effects of any progestin-containing birth control.
Fatigue.
Decreased sex drive.
Acne.
Depression and Mood Changes(depression and agitation).
Weight gain.
Headaches.
Breast tenderness.
Mood changes.

Progestins used in contraceptives are referred to as second generation (levonorgestrel, norethisterone) and third generation (desogestrel, gestodene, norgestimate). The third generation progestins tend to have fewer male-like side effects and possibly may have a better effect on cholesterol levels than earlier progestins. (It is unclear whether they pose a higher risk for blood clots than older progestins.

Danazol. Danazol (Danocrine) is a synthetic substance that resembles a male hormone. It suppresses estrogen, and therefore menstruation, and is used (sometimes in combination with an oral contraceptive), to reduce dysmenorrhea, menorrhagia, fibroid size, and symptoms of endometriosis. It may also improve operative success rates in women with menorrhagia when used before ablation treatment. [See Endometrial Ablation , below.] Adverse side effects include facial hair, deepening of the voice, weight gain, acne, and dandruff. It may also increase the risk for unhealthy cholesterol levels. There are no studies to date showing the effects of long-term use. Pregnant women or those trying to become pregnant should not take this drug because it may cause birth defects. [For more detail on this drug, see Report # 74, Endometriosis or Report #63, Fibroids.]

Medical Treatments for Women with Bleeding Disorders

Desmopressin is a drug that stimulates the release of blood factors that are particularly important for women with certain bleeding disorders, especially von Willebrand disease. A 2001 US study found that high doses of a nasal spray containing desmopressin acetate, or DDAVP (Stimate), produced excellent results in treating menorrhagia in women with bleeding disorders, including von Willebrand disease and mild hemophilia. Side effects were mild to moderate. They include headache, nausea, and weakness.

WHAT ARE THE SURGICAL PROCEDURES USED FOR MENSTRUAL DISORDERS?

Women with heavy menstrual bleeding, dysmenorrhea, or both now have surgical and medical options available to them. Some surgical procedures eliminate the possibility for childbearing but in women for whom this is not an issue, surgery (in comparison to drug treatments) may be a better decision. In one 1999 English study 79% of women who had chosen endometrial resection were satisfied with their decision after two years compared to only 57% who had decided to treat their problems with medication. Of the women who had used medication, only 24% recommended this path.

Endometrial Ablation or Resection

In either endometrial ablation or endometrial resection, the entire lining of the uterus (the endometrium) is removed or destroyed. Both ablation and resection are effective in reducing bleeding. At least 90% of women find either procedure acceptable and three-quarters are totally or generally satisfied with the treatment. Some experts are now recommending ablation as the first line option for surgical treatment of menorrhagia.

Endometrial Resection. Resection procedures benefit those women who have very heavy menstrual bleeding but do not have any other underlying uterine problems, such as polyps, hyperplasia of the endometrium, or cancer. Resection also seems to have a higher success rate in reducing bleeding and relieving pain in older women than younger women.

Resection procedures typically involve the following:

The patients are given a local or general anesthesia.
The physician dilates (widens) the cervix and fills the uterine cavity with fluid to improve visualization.
Standard resection uses an electrosurgical wire loop to remove the lining. A newer resection device called the IntraUterine Shaver is being investigated in Europe. It uses a tiny surgical blade set within a specially designed hysteroscope to mechanically remove uterine tissue. Only a few women have undergone this treatment, but it is a promising new resection technique that is minimally invasive and has lower risks for serious complications.

Standard Endometrial Ablation. Endometrial ablation uses the following approach:

The physician uses hysteroscopy to view the uterine cavity. This is a fiber optic light source inside a long flexible or rigid tube, which is inserted into the uterus in order to view the cavity. The image of the uterine cavity is transmitted by camera lenses to a video screen.
The uterine cavity is filled with fluid for better visualization. A special substance such as glycine, sorbitol, or mannitol may be added to the fluid so that it does not conduct electricity. This process prevents accidental burns.
With ablation, uterine tissue is usually vaporized using a thin powerful laser beam or high electric voltage. One ablation technique, known as electrocautery with roller ball diathermy, uses a device that looks like a tiny steamroller. This device applies heat and destroys endometrial tissue as it rolls across the uterine lining.
The procedure typically takes 15 to 45 minutes. Although a general anesthetic is usually required, the patient can go home the same day.

Physicians are investigating a number of so-called blind ablation procedures that can be performed in the doctor's office and do not require hysteroscopy and fluid infusion. Results to date, however, are much poorer than those using hysteroscopy.

It takes about three months to determine whether the procedure has been effective. There should be a follow-up appointment about two weeks after the procedure. One study revealed 80% of the women were satisfied with ablation, however this was lower than the 89% satisfaction rate reported by women who had had hysterectomy. About 30% of women who have this procedure still require additional surgeries, including hysterectomies, within five years. The risk is higher in younger women.

Balloon Endometrial Ablation. A procedure called balloon ablation (ThermaChoice) is showing promise.

A balloon at the tip of a catheter tube is filled with fluid and inflated until it conforms to the walls of the uterus.
A probe in the balloon heats the fluid to destroy the endometrial lining.
After eight minutes the fluid is drained out and the balloon is removed.
Studies show that bleeding is controlled in 70% to 90% of patients for at least one year.

Some research suggests that when performed by an experienced surgeon, it is safer than hysterectomy and other forms of ablation. As of 2001, success rates were similar to roller ball ablation. Pregnancy is possible if some of the lining is maintained, but generally infertility is the result.

Postoperative Effects and Complications of Endometrial Ablation or Resection Procedures

Postoperative Effects

Anesthesia may cause nausea and even vomiting for a few hours following the operation.
Cramping and pain occurs but can usually be relieved using over-the-counter painkillers.
Patients may experience frequent urination for the first day after the procedure and blood-tinged, watery vaginal discharge for more than a month.

Complications

Complications from the procedures may include perforation of the uterus, injury to the intestine, hemorrhage, or infection. (These are uncommon, however.)
In rare instances, excess glycine from the fluid instilled in the uterus builds up in the bloodstream and causes an abnormal drop in sodium levels. This can be a serious event resulting in mental confusion, convulsions, and very rarely, death. General anesthesia may pose a lower risk for this complication than local.

Investigative and Other Techniques to Destroy Endometrial Tissue

Endometrial laser intrauterine thermotherapy (ELITT) is an ablation technique that does not require either fluid or devices for expanding the uterus or direct contact with the endometrium. It is showing great promise and has the highest rates for reducing bleeding of all techniques tested to date. Studies are showing a success rates exceeding 90% after one year. More studies are warranted.
Microwave and freezing (cryoablation) techniques are also being used to destroy the uterine lining. Microwave endometrial ablation applies very low-power microwaves to the uterus, which limits tissue destruction only to the lining without causing any unnecessary harm to other tissues. It takes about three minutes.
An interesting investigative technique (Novacept RF Ablation Generator) employs an inflated device that uses radiofrequency to deliver power and evenly destroy uterine tissue. A suction device then removes moisture.

Hysterectomy

In 1995 nearly 600,000 hysterectomies were performed, and researchers are hopeful that new resection or ablation techniques will reduce this rate. The most common reasons for hysterectomy are menorrhagia (particularly bleeding that is due to fibroids) and endometriosis. In about 40% of the surgeries, the ovaries are removed (oophorectomy), which causes premature menopause in younger women. One study found that only 58% of hysterectomies were necessary, for 25%, the indications were uncertain, and for 16% the surgery was not appropriate. To date, few reliable studies have been done to help determine which patients would most benefit from hysterectomies when a noncancerous condition is involved. Physicians, therefore, do not have completely reliable data from which they can determine conclusively whether a hysterectomy is required or whether nonsurgical treatments or no treatment at all would be as effective. The patient should be sure that her surgeon is experienced in all techniques that apply to her specific condition. If the patient is at all uncertain, or believes she has not been given sufficient information, she should not feel embarrassed to seek a second opinion. Even the best surgeons and physicians do not always have all the answers to questions concerning hysterectomies. Making the best decision possible before surgery will help to reduce the emotional repercussions afterward. [For more details on hysterectomy see either Report #73, Fibroids: Uterine or Report #74, Endometriosis.]

WHERE ELSE CAN HELP BE OBTAINED FOR MENSTRUAL DISORDERS?

National Women's Health Resource Center, 2425 L Street NW, Washington, DC 20037. Call (202-293-6045) or on the Internet (http://www.womens-health.com)

National Women's Health Network, 514 10th St. NW, Suite 400, Washington, DC 20004. Call (202-347-1140) or (202 628 7814) for health information. Membership is $25 per year and provides a bimonthly newsletter and access to information. Reports cost $6.00 for members and $8.00 for nonmembers.

American College of Obstetricians and Gynecologists, Resource Center, 409 12th Street SW, Washington, DC 20024. Call (202638-5577) or on the Internet (http://www.acog.com/)

RESOLVE, Inc., 1310 Broadway, Somerville, MA 02144-1731. Call (617-623-1156) or the National HelpLine (617-623-0744) or on the Internet (http://www.resolve.org/)

American Society for Reproductive Medicine (Formerly the American Fertility Society), 1209 Montgomery Highway, Birmingham, AL 35216-2809. Call (205-978-5000) or on the Internet (http://www.asrm.com/current/practice/opinion.html)

The Endometriosis Association, 8585 N. 76th Place, Milwaukee, WI 53223 call (800-992-3636) for a general information packet or (414-355-2200) for specific issues or on the Internet (http://www.endometriosisassn.org/) This international association provides information, support, and research.

Fertility Research Foundation, 877 Park Avenue, New York, NY 10021. Call (212-744-5500) Offers information on treatment, latest research on male and female infertility.

International Pelvic Pain Society, Women's Medical Plaza, Suite 402, 2006 Brookwood Medical Center Drive Birmingham, Alabama 35209 USA. Call (1-800-624-9676) or (205-877-2950) or on the Internet (http://www.pelvicpain.org/)

Menopause News, 2074 Union Street, San Francisco, CA 94123 USA. Call (800-241-MENO) or on the Internet (http://wwwwellcom/user/mnews/)

Other Good Internet Sites for Women's Health ;

(http://www.womenshealth.org/)

(http://painnet.com/) This site offers live counseling on pain. It is a sponsored site and not non-profit, but may be helpful.

(http://www.estronaut.com)