mittelschmerz

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.

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