Defined as menstruation at regular cycle intervals, but with excessive blood flow and duration, menorrhagia is one of the most common gynaecological complaints women seek treatment for. It is estimated to affect 30% of all women in reproductive age with information from the World Health Organization indicating that up to 18 million women worldwide have been diagnosed with heavy menstrual bleeding (HMB) that not only interferes with their physical, social, emotional and/or material quality of life, but can also lead to more serious conditions such as anaemia.
In women with menorrhagia, menstrual bleeding can last for more than seven days. The flow is heavy, often consisting of clots and requires frequent changing of tampons or pads. In most cases, it is accompanied by painful contractions in the uterus (dysmenorrhea) that can be mild to severe, typically lasting from 12 to 72 hours as well as nausea and vomiting, fatigue, headache and even diarrhoea. Patients also complain of pain in the hips, lower back and inner thighs and a feeling of pressure in the abdomen. Although there are quantitative clinical definitions of heavy menstrual bleeding, the diagnosis is mainly based on subjective experience of the problem. One of the tools to assess the severity of menorrhagia is the Pictorial Blood Loss Assessment Chart (PBLAC), which uses the number of sanitary pads or tampons used per day and how heavily they are soiled to establish a score that is used to determine whether it is normal bleeding or HMB.
Patients who frequently lose more than 80 ml of blood during their periods are likely to develop iron-deficiency anaemia as a result of their blood loss. Menorrhagia is the most common cause of anaemia in premenopausal women.
Age and certain medical conditions are the main risk factors. In adolescent girls, anovulation is often the cause. In older reproductive-age women, uterine pathology, including fibroids, polyps and adenomyosis is the main cause.
But although common, menorrhagia is a condition that is often undertreated which could lead to potentially avoidable medical procedures. Successful treatment is therefore highly dependent on a thorough understanding of the exact aetiology.
Aetiologies of menorrhagia are divided into 4 categories: organic, endocrinologic, anatomic, and iatrogenic. Organic causes are infection, bleeding disorders, including Von Willebrand diseases and prothrombin deficiency; and organ dysfunction such as hepatic or renal failure. Endocrinologic causes include thyroid and adrenal gland dysfunction, pituitary tumours, anovulatory cycles, PCOS, obesity, and vasculature imbalance. Uterine fibroids, endometrial polyps, endometrial hyperplasia, and pregnancy are some of the anatomic causes of menorrhagia. Iatrogenic causes include IUDs which can cause increased bleeding and cramping; steroid hormones that can disrupt the normal menstrual cycle, and medications such as anticoagulants which can lead to heavy bleeding.
Medical therapy for menorrhagia should be tailored to the individual and depends on the cause and seriousness of the bleeding. Factors that should be taken into consideration when selecting appropriate medical treatment include the patient’s age, coexisting medical diseases, family history, and desire for fertility.
Main therapeutic options are:
- · Hormonal treatment, e.g., contraceptives, which have been shown to reduce menstrual flow volume.
- · Non-hormonal therapies including non-steroidal anti-inflammatory drugs (NSAIDs), which have been shown to reduce menstrual bleeding by decreasing prostaglandin levels, and certain antifibrinolytics, while also reducing pain.
- · Tranexamic acid, a non-hormonal treatment that has been approved for heavy menstrual bleeding. It is a synthetic derivative of lysine that inhibits the activation of plasminogen to plasmin.
- · Surgical management is used when the cause is organic or when medical therapy fails to alleviate symptoms. Options for surgical intervention include hysterectomy, resectoscopic endometrial ablation and nonresectoscopic endometrial ablation.
- · Alternative treatment options include the herb capsella bursa-pastoris, also known as Shepherd’s purse. It has been shown to significantly reduce the volume of blood loss in women with HMB. The herb has been used for decades to treat bleeding of various causes, such as uterine bleeding and postpartum haemorrhage. Consisting of compounds such as tannins, choline, acetylcholine, flavonoids, amino acids, fatty acids, sterols, thiamine, ascorbic acid, calcium, potassium, beta-carotene, vitamin K, niacin, and iron, it has been shown to increase smooth muscle contraction in the uterus, thereby facilitating the regulation of menstrual blood flow. Salome, consisting of 40 mg dry extract of Capsella bursa-pastoris will soon be available in South Africa and is indicated for the symptomatic treatment of heavy menstrual bleeding in women with regular menstrual cycles.
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