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Heavy Bleeding (Menorrhagia)
- 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.
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.
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.
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) .
progesterone, and testosterone are
secreted by the ovaries at the command of FSH and LH and complete
the hormonal group necessary for reproductive health.
Processes Leading to Menstruation
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:
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.
- the follicular
- the luteal
(or secretory) phase.
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 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)
- 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.
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.
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
- 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.
the endometrial lining sloughs off and is shed during menstruation.
No. of Days
Follicular (Proliferative) Phase
Days 1 through 6: Beginning of menstruation to end of blood
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
Days 7 - 13: The endometrium (the inner portion or lining
of the uterus) thickens to prepare for the egg implantation.
Surge in LH. Largest follicle bursts and releases egg into
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
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
Factors for Shorter Cycles
Factors for Longer Cycles
Regular alcohol use.
Being under 21 and over 44.
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
Normal Absence of Menstruation. Normal absence of periods
can occur in any woman under the following circumstances:
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.
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.
IS MENORRHAGIA (HEAVY MENSTRUAL BLEEDING) AND OTHER MENSTRUAL
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:
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.)
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.)
regularly last more than eight to ten days.
(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.
(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.
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.
amenorrhea occurs when periods that were previously regular
become absent for at least three cycles. [For more details,
see the Report # 101, Amenorrhea.]
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.
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.
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.
dysmenorrhea is menstrually related pain that is caused by other
medical conditions, usually endometriosis or pelvic abnormalities.
[For more Information see the Report #100,
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,
79, Premenstrual Syndrome .]
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.
Associated with a Higher Risk for Heavy Menstrual Bleeding
characteristics are associated with a higher risk for menorrhagia:
older. (Women who have late periods or are approaching menopause
may experience occasional menorrhagia.)
a higher number of pregnancies.
Conditions that Cause Heavy Menstrual Bleeding
A number of conditions
are known to contribute to menorrhagia, including the following:
[For more information, see the Report
polyps. (These are small benign growths in the uterus.)
- A retroverted
uterus (so-called tipped uterus).
contraceptives. (Oral contraceptives or an intrauterine device,
- 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.
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.
(These are small implants of uterine tissue. They are more likely
to cause pain than bleeding.)
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
drugs, including anticoagulants and anti-inflammatory medications,
can also cause heavy bleeding.
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
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
SERIOUS IS HEAVY MENSTRUAL BLEEDING?
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.
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.
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 .]
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.
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.
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.
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.
A physician will
perform a pelvic examination to check for pregnancy-related conditions
or any abnormalities, such as ovarian cysts or fibroids.
The use of a
pictorial assessment chart is proving to be a very accurate method
for self-reporting menstrual blood loss.
and Personal History
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
- 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.)
use of any medications (including vitamins and over-the-counter
- Diet history,
including caffeine and alcohol intake.
- Past or
present contraceptive use.
- Any recent
history. (It is very important that the patient trust the physician
enough to describe any sexual activity that might be risky.)
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.
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
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.
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:
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.
- 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.
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
ARE THE HOME REMEDIES FOR MENSTRUAL SYMPTOMS AND HEAVY MENSTRUAL
Recommendations for Preventing Menstrual Cramps and Other Symptoms
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:
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
- Eat plenty
of whole grains, fresh fruits and vegetables.
saturated fats and commercial junk foods.
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.
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
CAN A WOMAN PREVENT IRON-DEFICIENCY ANEMIA FROM HEAVY MENSTRUAL
Recommendations for Preventing Anemia
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.
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.)
- 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.
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.)
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.
containing riboflavin (vitamin B2) may help enhance the response
of hemoglobin to iron. Sources include liver, dried fortified
cereals, and yogurt.
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.
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
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.
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:
The general guidelines for iron replacement are as follows:
ferrous sulfate (Slow Fe) may enhance iron absorption with fewer
side effects than standard ferrous sulfate pills.
contains a stool softener, which helps prevent constipation.
complex has fewer side effects than and has equal absorption
rates to ferrous salts. It is very expensive, however.
iron is composed of very fine tiny uniform spheres of iron powder
and may prove to be less toxic than ferrous iron.
or combination pills do not appear to offer any additional advantages
and may hinder absorption of the iron.
No one, even
adults, should take a double dose of iron if one is missed.
- 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
Other tips for taking iron are as follows:
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.
- 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.
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).
Side Effects. Common side effects of iron supplements include
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.
and diarrhea are very common. They are rarely severe, although
iron tablets can aggravate existing gastrointestinal problems
such as ulcers and ulcerative colitis.
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.
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
- 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.
iron poisoning is rare in adults but can be fatal in children
who take adult-strength tablets.
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
ARE THE DRUG TREATMENTS FOR HEAVY MENSTRUAL BLEEDING?
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.
Hormonal agents are useful for women with heavy bleeding who
also want to control the menstrual cycle.
- The first
options are nonsteroidal anti-inflammatory drugs, with reported
reductions in menstrual blood loss of 25% to 35%.
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.
- 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.)
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.
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
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.
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.
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.]
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.
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.
Attacks. Smoking and high blood pressure may also increase the
risk for heart attacks in women taking OCs.
- 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.
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
- 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
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:
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:
Nausea and vomiting. (Can often be controlled by taking
the pill during a meal or at bedtime.)
Breast tenderness and enlargement.
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.
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.
Decreased sex drive.
Depression and Mood Changes(depression and agitation).
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,
or Report #63, Fibroids.]
Treatments for Women with Bleeding Disorders
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.
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.
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:
Ablation. Endometrial ablation uses the following approach:
- 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.
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.
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.
- 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
- The procedure
typically takes 15 to 45 minutes. Although a general anesthetic
is usually required, the patient can go home the same day.
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
Balloon Endometrial Ablation. A procedure called balloon
ablation (ThermaChoice) is showing promise.
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
- 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.
eight minutes the fluid is drained out and the balloon is removed.
show that bleeding is controlled in 70% to 90% of patients for
at least one year.
Postoperative Effects and Complications of Endometrial Ablation
or Resection Procedures
Anesthesia may cause nausea and even vomiting for a few
hours following the operation.
Cramping and pain occurs but can usually be relieved using
Patients may experience frequent urination for the first
day after the procedure and blood-tinged, watery vaginal
discharge for more than a month.
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
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.
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
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.]
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 (https://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
American College of Obstetricians and Gynecologists, Resource Center,
409 12th Street SW, Washington, DC 20024. Call (202638-5577) or
on the Internet (https://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 (https://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 (https://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 (https://www.endometriosisassn.org/)
This international association provides information, support, and
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
Menopause News, 2074 Union Street, San Francisco, CA 94123 USA.
Call (800-241-MENO) or on the Internet (https://wwwwellcom/user/mnews/)
Other Good Internet Sites for Women's Health ;
This site offers live counseling on pain. It is a sponsored site
and not non-profit, but may be helpful.