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Heavy and prolonged periods

Average blood loss during menstruation is about 40 cc, or about 3 tablespoons. Abnormally heavy bleeding is defined as about 80 cc (over 5 tablespoons), while some women with very heavy periods can lose up to a pint of blood with each menstrual cycle.  When flows are this heavy, anemia is often present.  Iron supplementation helps, but often is not enough to keep up with the demand for new red blood cells.(In most women, heavy periods are not a sign of serious illness, but in some, increasingly when women are over the age of 40, heavy bleeding can be a sign of cancer of the endometrium, the lining of the uterus that sheds with each menstruation.

For this reason, when heavy and/or irregular bleeding occurs in women in this age group, a sampling, or biopsy, of the uterine lining is often done during the course of an office visit.) Treatment for this problem starts with non-steroidal anti-inflammatory medications (e.g. ibuprofen) that a woman starts taking regularly about five days before the beginning of each period and continues while the flow is present.  This reduces blood loss about 30% on average. Oral contraceptives help reduce menstrual flow and make it regular as well.  Additional options include continuous oral progesterone (Provera, norethindrone), intramuscular progesterone (depo-Provera), or the progesterone IUD (Mirena).

When child-bearing is complete, there are more treatment options for heavy periods. First, there are hormonal treatments such as those listed above, and there are a variety of ways of treating the lining of the uterus (endometrium) that reduce (or eliminate) menstrual flow.  These are called “endometrial ablation.”

There are about 8 different techniques that have been developed, all of which are appropriate to use when the goal is to reduce menstrual flow.  Depending on the technique used, between 50 and 80% of women treated with these methods will still have periods (although much lighter).  Second, there are the surgical methods of removing the uterus (hysterectomy).  Long-term studies of patient satisfaction have shown that women having hysterectomy more often end up pleased with the results than do women who have had endometrial ablation.

Irregular bleeding

The length of the average menstrual cycle is 28 days, but the range of “normal” is wide, from 22-35 days.  Menstrual cycles tend to be more irregular in young teenage women for the first few years of menstruation, and again in the 40’s, during the 3-5 years prior to menopause.  A number of medical conditions can cause irregular periods, including thyroid disease, rapid gain or loss of weight, and virtually any significant chronic illness.

Probably the most common cause of irregular bleeding is a side effect of taking oral contraceptive pills.  Although this is less of a problem now than it used to be, due to better birth control pills being available, it is still the single most common reason women report for discontinuing pills. Many times, changing types of pills will help, or sometimes simply taking a break from the pill for a few months stops the problem.

In women over the age of 30 or 35, abnormal changes in the lining of the uterus start to be more common explanations for irregular bleeding and “breakthrough” bleeding in between periods.  Most of these changes are not due to cancer.  Polyps are small (usually 1-2 cm) round lumps of uterine lining (endometrium) that can form and sometimes will bleed at odd times.  They can be removed, usually quite easily, by performing a hysteroscopy.

Finally, another common cause of irregular, and sometimes heavy bleeding is the presence of a fibroid (benign growth of uterine muscle wall) directly under the endometrial lining of the uterus.  Some of these can be removed during a hysteroscopy, but others will require uterine artery embolization or hysterectomy.  Sometimes, the fibroid or fibroids can be removed surgically, in a myomectomy.