menorrhagia

At some time in your reproductive life, you've probably experienced heavy bleeding during your menstrual period. If you're like some women, every period you have causes enough blood loss and cramping that you can't maintain your usual daily activities. The medical term for periods like these — excessive or prolonged or both — is menorrhagia.

Although heavy menstrual bleeding is a common concern among premenopausal women, few women experience blood loss severe enough to be defined as menorrhagia. If you have menstrual bleeding so heavy that you dread your period, talk with your doctor. There are many effective treatments for menorrhagia.

Normal menstrual flow:

• Occurs every 21 to 35 days
• Lasts four to five days
• Produces a total blood loss of about 2 to 3 tablespoons (30 to 44 milliliters)

The menstrual cycle isn't the same for every woman. Your period may be regular or irregular, light or heavy, painful or pain-free, long or short and still be considered normal. Menorrhagia refers to losing about 5 1/2 tablespoons (81 milliliters) or more of blood during your menstrual cycle.

The signs and symptoms of menorrhagia may include:

• Menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours
• The need to use double sanitary protection to control your menstrual flow
• The need to change sanitary protection during the night
• Menstrual periods lasting longer than seven days
• Menstrual flow that includes large blood clots
• Heavy menstrual flow that interferes with your regular lifestyle
• Tiredness, fatigue or shortness of breath (symptoms of anemia)

When to see a doctor
Doctors generally recommend that all sexually active women and women over the age of 21 have yearly pelvic exams and regular Pap tests. However, if you experience heavy or irregular vaginal bleeding, schedule an appointment with your doctor and be certain to record when the bleeding occurs during the month. If you're having heavy vaginal bleeding — soaking at least one pad or tampon an hour for more than a few hours — seek medical help. Call your doctor if you have any vaginal bleeding after menopause.

In some cases, the cause of heavy menstrual bleeding is unknown, but a number of conditions may cause menorrhagia. Common causes include:

• Hormonal imbalance. In a normal menstrual cycle, a balance between the hormones estrogen and progesterone regulates the buildup of the lining of the uterus (endometrium), which is shed during menstruation. If a hormonal imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding.
• Dysfunction of the ovaries. Lack of ovulation (anovulation) may cause hormonal imbalance and result in menorrhagia.
• Uterine fibroids. These noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.
• Polyps. Small, benign growths on the lining of the uterine wall (uterine polyps) may cause heavy or prolonged menstrual bleeding. Polyps of the uterus most commonly occur in women of reproductive age as the result of high hormone levels.
• Adenomyosis. This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and pain. Adenomyosis is most likely to develop if you're a middle-aged woman who has had many children.
• Intrauterine device (IUD). Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for birth control. When an IUD is the cause of excessive menstrual bleeding, you may need to remove it.
• Pregnancy complications. A single, heavy, late period may be due to a miscarriage. If bleeding occurs at the usual time of menstruation, however, miscarriage is unlikely to be the cause. An ectopic pregnancy — implantation of a fertilized egg within the fallopian tube instead of the uterus — also may cause menorrhagia.
• Cancer. Rarely, uterine cancer, ovarian cancer and cervical cancer can cause excessive menstrual bleeding.
• Inherited bleeding disorders. Some blood coagulation disorders — such as von Willebrand's disease, a condition in which an important blood-clotting factor is deficient or impaired — can cause abnormal menstrual bleeding.
• Medications. Certain drugs, including anti-inflammatory medications and anticoagulants (to prevent blood clots), can contribute to heavy or prolonged menstrual bleeding. Improper use of hormone medications also can cause menorrhagia.
• Other medical conditions. A number of other medical conditions, including pelvic inflammatory disease (PID), thyroid problems, endometriosis, and liver or kidney disease, may cause menorrhagia.

Menorrhagia is most often due to a hormonal imbalance that causes menstrual cycles without ovulation. In a normal cycle, the release of an egg from the ovaries stimulates the body's production of progesterone, the female hormone most responsible for keeping periods regular. When no egg is released, insufficient progesterone can cause heavy menstrual bleeding.

Menstrual cycles without ovulation (anovulatory cycles) are most common among two age groups:

• Adolescent girls who have recently started menstruating. Girls are especially prone to anovulatory cycles in the first year and a half after they have their first menstrual period (menarche).
• Older women approaching menopause. Women ages 40 to 50 are at increased risk of hormonal changes that lead to anovulatory cycles.

Excessive or prolonged menstrual bleeding can lead to other medical conditions, including:

• Iron deficiency anemia. In this common type of anemia, your blood is low on hemoglobin, a substance that enables red blood cells to carry oxygen to tissues. Low hemoglobin may be the result of insufficient iron. Menorrhagia may deplete iron levels enough to increase the risk of iron deficiency anemia. Signs and symptoms include pallor, weakness and fatigue.

  Although diet plays a role in iron deficiency anemia, the problem is complicated by heavy menstrual periods. 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 and headaches.

• Severe pain. Heavy menstrual bleeding often is accompanied by menstrual cramps (dysmenorrhea). Sometimes the cramps associated with menorrhagia are severe enough to require prescription medication or a surgical procedure.

Your doctor will most likely ask about your medical history and menstrual cycles. You may be asked to keep a diary of bleeding and nonbleeding days, including notes on how heavy your flow was and how much sanitary protection you needed to control it. Your doctor will do a physical exam and may recommend one or more tests or procedures such as:

• Blood tests. A sample of your blood is evaluated in case excessive blood loss during menstruation has made you anemic. Tests may also be done to check for thyroid disorders or blood-clotting abnormalities.
• Pap test. Your doctor collects cells from your cervix for microscopic examination to detect infection, inflammation or changes that may be cancerous or may lead to cancer.
• Endometrial biopsy. Your doctor takes a sample of tissue from the inside of your uterus to be examined under a microscope.
• Ultrasound scan. This imaging method uses sound waves to produce images of your uterus, ovaries and pelvis.

Based on the results of your initial tests, your doctor may recommend further testing, including:

• Sonohysterogram. This ultrasound scan is done after fluid is injected through a tube into the uterus by way of your vagina and cervix. This allows your doctor to look for problems in the lining of your uterus.
• Hysteroscopy. A tiny tube with a light is inserted through your vagina and cervix into the uterus, which allows your doctor to see the inside of your uterus.
• Dilation and curettage (D and C). In this procedure, your doctor opens (dilates) your cervix and then inserts a spoon-shaped instrument (curet) into your uterus to collect tissue from the uterine lining. This tissue is examined in the laboratory.

Doctors can be certain of a diagnosis of menorrhagia only after ruling out other menstrual disorders, medical conditions or medications as possible causes or aggravations of this condition.

Consider these tips for successful self-care of menorrhagia:

• Get your rest. Your doctor may recommend rest if bleeding is excessive and disruptive to your normal schedule or lifestyle.
• Keep a record. Record the number of pads and tampons you use so that your doctor can determine the amount of bleeding. Change tampons regularly, at least every four to six hours.
• Avoid aspirin. Because aspirin interferes with blood clotting, avoid it. However, other nonsteroidal anti-inflammatory medications, such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve), often are very effective in relieving menstrual discomfort.

changing of pads/tampons

Question: When Should I Change Tampons or Pads during My Periods?

Answer: During your periods, pads or sanitary napkins should be changed as often as necessary to prevent the pad from becoming soaked with menstrual flow. You will learn to know how long you feel comfortable before you change pads during your periods.

If you use tampons during your periods make sure you change them at least every 4 to 8 hours to help prevent a rare, but potentially fatal disease called toxic shock syndrome or TSS. Always use the lowest absorbency tampon necessary for the amount of menstrual flow you are experiencing on each day of your period. Using super absorbency tampons on the lightest day of your period potentially puts you at risk for toxic shock syndrome. Those most at risk for TSS include women under thirty, particularly teenage girls.

Don’t believe it if someone tells you that only certain types of tampons put you at risk for TSS. That just isn’t true. It doesn’t matter if the tampon is made of the purest cotton or of rayon, or what absorbency it is – all tampons put you at risk for toxic shock syndrome.

Your risk for toxic shock syndrome may be lessened by alternating between tampons and pads. For example, many women use tampons during the day and pads at night during their periods. Other methods for reducing your risk for toxic shock syndrome and other problems resulting from tampon use that are recommended by the Food and Drug Administration or FDA include:

• Always read and follow the directions for tampon insertion on the brand that you purchase.

• Learn which absorbency is right for your menstrual flow and choose the appropriate tampon absorbency.

• Change your tampon at least every 4 to 8 hours.

• Think about alternating pads with tampons.

• Know the signs and symptoms of toxic shock syndrome.

• Don’t use tampons between periods.

  Reference: NWHIC

how to relieve menstrual cramps at home

Answer: If you are one of the millions of women who experience menstrual cramps during your period, you’ll want to know what you can do to help relieve the pain. One of my favorite ways to reduce menstrual cramps is placing a heating pad placed on the lower abdomen, just below the belly button.

Other self-help measures include taking warm baths or showers, drinking warm beverages, and giving yourself a light massage by making circular motions with your fingertips around your lower abdomen. Make sure to schedule free time for yourself to relax and take care of yourself during the time of the month when you expect your periods.

Eating light, frequent meals and following a diet that is rich in complex carbohydrates (whole grains, fruits, and vegetables) and low in salt, sugar, alcohol, and caffeine also helps reduce painful menstruation for some women. It’s especially important for women who experience bloating or fluid retention during menstruation to lower their salt consumption, since excess salt intake can cause fluid retention.

Regular physical activity works wonders at reducing many of the symptoms of PMS, including menstrual cramps. If you’re under stress, like many of us are, you might also want to learn to distress and relax your body and mind through meditation or yoga.

Anti-inflammatory drugs, such as ibuprofen, which are available without a prescription, often provide effective relief from painful menstrual cramps.

If you have PMS as well as menstrual cramps, you may want to try taking supplements such as vitamin B complex, essential fatty acids, calcium, and magnesium. The following supplemental amounts are in addition to the amount in a daily multi-vitamin and mineral supplement, which all women should take regularly:

• 1200 mg of calcium in two divided doses
• 250 mg of magnesium
  (If you experience constipation or diarrhea while taking magnesium, talk to your doctor. You may need to increase or decrease the amount of magnesium you take.)
• Supplemental vitamin B6 varies from 50 to 200 mg
• 50 mg of vitamin B1

Fish oil capsules may be helpful for women who have PMS, as well as menstrual cramps. Fish oil capsules contain the essential fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The recommended schedule for fish oil capsules is 1000 mg of EPA and 700 mg of DHA, taken in two divided daily doses for two months. You should always take vitamin E supplement when supplementing with fish oil capsules.

Finally, some women find it helpful to keep their knees bent whenever they are lying down, which reduces the stretching of the pelvic muscles. If you sleep on your back, use a pillow under your knees to keep your legs bent. If you’re a side sleeper, try holding a pillow pressed to your lower abdomen with your knees bent.

_Source:

_{Painful Menstrual Periods; Medline Plus Medical Encyclopedia; http://www.nlm.nih.gov/medlineplus/ency/article/003150.htm; accessed 05/21/08. Cyclic Perimenstrual Pain and Discomfort: Nursing Management. Evidence Based Clinical psPractice Guideline; http://www.guidelines.gov/summary/summary.aspx?doc_id=7199&nbr=004302; accessed 06/23/08}

premenstrual syndrome

If you think you might have premenstrual syndrome or PMS, you are not alone. In fact, about three-quarters of all girls and women experience PMS during their reproductive lives. A syndrome is a group of symptoms that occur together and that are characteristic of a disease or condition. Premenstrual syndrome is present when certain physical and / or emotional signs or symptoms occur.

PMS Diagnostic Criteria

The University of California, San Diego has developed the most widely used and accepted diagnostic criteria for diagnosing PMS. Although over 150 symptoms have been associated with PMS, women must self-report at least one of the following physical symptoms of PMS and at least one of the following mental symptoms of PMS. Additionally, these symptoms must occur during the five days before menstruation begins to meet the diagnostic criteria for premenstrual syndrome.

The Physical Symptoms of PMS

• Sore, tender breasts
• Headache
• Abdominal bloating (the most common physical symptom)
• Swelling of the extremities

Mental Symptoms of PMS

• Fatigue (the most common mental symptom)
• Angry outbursts or mood swings
• Irritability
• Confusion
• Social withdrawal

All symptoms must disappear by Day 4 of the menstrual cycle and must not occur before Day 14 (of the average 28-day menstrual cycle) to meet the criteria for a diagnosis of PMS. The final requirement for a diagnosis of PMS is that symptoms must be present in the absence of any pharmacological treatments, hormone ingestion, or drug or alcohol use.

A true diagnosis of PMS causes identifiable dysfunction in social or economic performance and includes at least one of the following:

• Marriage or relationship problems which are confirmed by the partner of the woman seeking diagnosis of PMS
• Parenting difficulties
• Decreased performance and / or attendance problems, including being late, at school or work
• Less than normal amount of social activity during the premenstrual period of the menstrual cycle
• Legal issues
• Suicidal thoughts, words, or actions
• Seeking medical attention for physical symptoms of PMS

Some girls and women experience a more severe form of PMS called premenstrual dysphoric disorder, or PMDD. The diagnostic criteria for PMDD includes the above criteria as well as the presence of additional symptoms.

If you think, you have the symptoms of premenstrual syndrome see your physician for diagnosis and treatment. Getting a diagnosis of PMS requires keeping a menstrual cycle calendar for two or three menstrual cycles to reflect a pattern of symptoms.

_Sources:

_{The American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, American Psychiatric Association 1994.}

_{Robert F Casper, MD. Patient information: Premenstrual syndrome and premenstrual dysphoric disorder (PMDD), Clinical manifestations and diagnosis of premenstrual syndrome and premenstrual dysphoric disorder, UpToDate [online]; accessed 10/24/2006.}

Getting Your Period

Probably the most talked about event of puberty for a girl is her period. Getting your period is another way of talking about menstruation.

Within about a year after beginning her growth spurt, most girls will have their first period. This marks the beginning of a girl's life as a young woman. In some cultures, this is celebrated publicly. Others choose to be more private about it. Some girls can't wait for their first period to come, while others may dread it or feel neutral about it. No matter how you feel, it's an important event in your life and part of the normal process of becoming an adult.

Most American girls start their periods between the ages of 9 and 15. There really isn't any way you can tell the day or week you'll get your first period. There also isn't really any way you can make it come sooner or delay it from happening. But you can understand what is happening inside your body to know what is normal for you.

During each period, the inner lining of your uterus is shed through the vagina, the passage that connects your inner reproductive organs to your outer sex organs or genitals. This lining is mostly blood and other tissues that have been building up since your last period. The purpose of this blood is to provide nutrients for a fertilized egg if you were to become pregnant. Girls start having their periods early in heir lives, but most don't decide to start a family till they've already been having their periods for many years. Most women stop having periods when they are between 45 and 55 years old. This is called menopause.

You may have heard some women talking about their monthly cycle. This cycle begins on the first day of one period and ends on first day of the next period. While women's periods do tend to come about once per month, there is a wide range in the length of menstrual cycle from woman to woman. Some women's periods come as often as every 21 days, some as far apart as every 35 days. The most common range is 25-30 days. Some women have regular cycles and their periods start exactly the same number of days apart each time. For other women, the length of their cycle varies from month to month.

There is also a great range in how much blood flow each woman loses during her period. You may have a heavy flow and need to change your pad or tampon frequently. Or you may have a light flow with barely any blood loss. Usually your flow will be heaviest at the beginning of your period. It may start out light, get heavier, and then get lighter again until it's over. It's also common to see some small clots or pieces of tissue in your menstrual blood. Most women's periods last from 3 to 7 days.

Another thing that can vary is the color of the blood on your tampon or pad. Sometimes the blood from your period can be a dark, rust-like color. Other times it can be a bright red color. The color may vary according to where you are in your period or the heaviness of your flow. Pay attention to the rhythm of your body, so you'll know what is normal for you in terms of flow, cycle and period length, and color of your blood.

~Adapted from the Women's Health Information Center

menstruation 101

Menstruation is the cyclic occurrence of uterine bleeding that occurs near the end of puberty in girls. Typically, first periods occur around age 12 or 13. However, some girls begin having periods as young as 8 or 9 years old, while others may be as old as 15 or 16. If menarche does not occur by the time a girl reaches the age of 16, she should see her doctor for evaluation. Menstruation usually begins about 2 1/2 years after girls begin developing breasts, and growing pubic and underarm hair.

Once menstruation begins, it continues until menopause occurs around the age of 50 when monthly menstrual cycles end. Surgical menopause occurs following removal of the ovaries during hysterectomy. Menstruation also temporarily stops during pregnancy. Hormonal contraceptives also stop normal menstruation and can safely be used to stop periods indefinitely or until pregnancy is desired. If menstruation fails to occur for any other reason, amenorrhea occurs. Amenorrhea is a menstrual cycle disorder.

For the most part, the menstrual cycle occurs predictably and without problems. However, when things don’t go right -– when you experience heavy or excessive bleeding, when your period doesn’t occur when expected, when you have physical or emotional symptoms during the weeks before you menstruation, or when you experience painful periods or other symptoms –- you may have a menstrual cycle disorder.

Abnormal uterine bleeding is a common menstrual cycle disorder that includes several types of abnormal bleeding patterns, including amenorrhea. Other menstrual cycle disorders include dysmenorrhea, premenstrual syndrome or PMS, premenstrual dysphoric disorder or PMDD, and uterine fibroid tumors. Other factors that may affect normal menstruation include stress, illness, exercise, diet and nutrition, and work, family, and relationship issues.

What Causes the Menstrual Cycle and Menstruation?

Your endocrine system produces hormones that work together with your reproductive organs to cause the menstrual cycle and menstruation when conception does not occur. The glands of the endocrine system produce hormones that regulate various bodily functions such as blood sugar levels, metabolism, and reproduction. The menstrual cycle occurs in distinct phases during which hormones cause the changes that prepare the uterus to sustain a pregnancy, and to cause menstruation when pregnancy does not occur.

How Often Does Normal Menstruation Occur?

The average menstrual cycle is 28 days and women menstruate, on average, about five to seven days during each cycle. The first day, or Day 1, of the menstrual cycle is the first day any bleeding occurs, even if it’s just spotting. It’s a good idea to use a calendar to keep track of your menstrual cycle. Tracking your periods and any symptoms that occur during the menstrual cycle can help your physician diagnose any problems that may occur.

How Much Blood Loss is Normal during Menstruation?

You might be surprised to learn that, while it might often seem like much more, the total amount of blood lost during menstruation is only a few tablespoons. You may be experiencing excessive bleeding if you have to change pads or tampons every hour or so for several hours in a row. Contact your health-care provider if you experience excessive bleeding during your period.

What to Tell Your Doctor about Your Period

When your first period occurs, make sure to inform your doctor. From that point on throughout your reproductive years, your doctor appointments should include notation of the first day of your last period. Having a menstrual cycle calendar helps you to remember this information when asked. Other things you should tell your doctor about your period include:

• Having irregular, excessive, or other types abnormal bleeding
• Experiencing severe cramps during menstruation that is not relieved by OTC pain-killers, or experiencing pelvic pain that is unrelated to menstruation
• Not having periods
• Having menstrual cycles that are less than 21 days, or more than 35 days apart
• Anything about your period, or menstrual cycle, that seems abnormal for you

Tip: Girls often have irregular periods during the first few years after menstruation begins. It’s completely normal to have irregular periods while your body adjusts to all the physical and emotional changes that occur during adolescence.

_Sources:

_{Getting Your Period; GirlsHealth.gov; http://www.girlshealth.gov/body/period.htm; accessed 07/10/07.}

All About Menstruation; Teens Health, KidsHealth.org; accessed 07/10/07.