What is menometrorrhagia

Menometrorrhagia is a condition in which prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal. Menometrorrhagia is thus a combination of metrorrhagia (bleeding between period or intermenstrual bleeding) and menorrhagia (heavy menstrual bleeding). With menorrhagia, you can’t maintain your usual activities when you have your period because you have so much blood loss and cramping. If you dread your period because you have such heavy menstrual bleeding, talk with your doctor. There are many effective treatments for menorrhagia.

Menometrorrhagia causes

Menorrhagia or heavy periods affect one in five American women each year ¹. If you have heavy bleeding, your periods may be so painful and heavy that you find it hard to do normal activities such as going to work or school.

Causes of menorrhagia include:

• Hormone 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 hormone imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding. A number of conditions can cause hormone imbalances, including polycystic ovary syndrome (PCOS), obesity, insulin resistance and thyroid problems.
  
• Problems with ovulation. In a normal menstrual cycle, your uterine lining builds up and thickens to prepare for pregnancy. If pregnancy does not happen, the uterine lining leaves your body during your period. If your hormones get out of balance or if you do not ovulate, the uterine lining can build up too much and bleed heavily and in an unpredictable pattern.
• Problems with the uterine lining. If your hormones or uterine lining get out of balance, the uterine lining can bleed too much. This can cause heavy bleeding as the lining is pushed out during the next menstrual period.
• Thyroid problems. Heavy bleeding can be a sign of hypothyroidism or underactive thyroid. Hypothyroidism happens when your thyroid does not make enough thyroid hormones.
• Uterine fibroids. Fibroids are made of muscle tissue that grows in or on the wall of the uterus. They are almost always not cancer. They can cause pain and heavy or irregular bleeding.
• Uterine polyps. Polyps are an overgrowth of the endometrial tissue that lines the inside of the uterine wall. They are usually small. They are usually not cancer but can cause heavy or long periods.
• Certain medicines. Some medicines, such as blood thinners, can cause heavy or long periods.
• Pregnancy problems. Unusual or not regular heavy bleeding can be caused by a miscarriage (an early pregnancy that ends) or an ectopic pregnancy. An ectopic pregnancy is when the fertilized egg implants outside of the uterus (womb) where it does not belong, putting a woman’s life in danger. Ectopic pregnancies can never end in a healthy pregnancy and are a medical emergency.
• Bleeding disorders. Hemophilia and von Willebrand’s disease are inherited bleeding disorders that cause heavy bleeding during periods. Studies show that up to one in five white women with heavy periods has a bleeding disorder. Bleeding disorders are less common in African-American women, affecting about one in 20 African-American women with heavy bleeding.14 For many women, heavy menstrual bleeding is the only sign they have a bleeding disorder.
• Dysfunction of the ovaries. If your ovaries don’t release an egg (ovulate) during a menstrual cycle (anovulation), your body doesn’t produce the hormone progesterone, as it would during a normal menstrual cycle. This leads to hormone imbalance and may result in menorrhagia.
• Obesity. The extra fat in the body makes the hormone estrogen. The extra estrogen changes the normal menstrual cycle and can cause missed, irregular, or heavy periods.
• Endometriosis. This condition happens when the lining of the uterus grows outside of the uterus where it does not belong.
• Polyps (growths) in your uterus or cervix. Small, benign growths on the lining of the uterus (uterine polyps) may cause heavy or prolonged menstrual bleeding.
• Adenomyosis. This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and painful periods.
• Inflammation or infection of the cervix (cervicitis)
• Inflammation or infection of the uterus (endometritis)
• Abnormalities in the cervix or uterus
• Ectopic pregnancy
• Start of a miscarriage
• Other pregnancy complications. A single, heavy, late period may be due to a miscarriage. Another cause of heavy bleeding during pregnancy includes an unusual location of the placenta, such as a low-lying placenta or placenta previa.
  
• Cancer or pre-cancer of the cervix, uterus, or (very rarely) fallopian tube. Uterine cancer and cervical cancer can cause excessive menstrual bleeding, especially if you are postmenopausal or have had an abnormal Pap test in the past.
• Injury or disease of the vaginal opening (caused by intercourse, trauma, infection, polyp, genital warts, ulcer, or varicose veins)
• Intrauterine device (IUD) use (may cause occasional spotting). Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for birth control. Your doctor will help you plan for alternative management options.
• Vaginal dryness due to lack of estrogen after menopause
• Stress
• Using hormonal birth control irregularly (such as stopping and starting or skipping birth control pills, patches, or estrogen rings)
• Use of blood thinners (anticoagulants)
• Pelvic exam, cervical biopsy, endometrial biopsy, or other procedures
• Ovarian cysts. Unusual bleeding may be a sign of an ovarian cyst that has ruptured (burst).
• Use of hormonal contraception
• Fertility treatments
• Medications. Certain medications, including anti-inflammatory medications, hormonal medications such as estrogen and progestins, and anticoagulants such as warfarin (Coumadin, Jantoven) or enoxaparin (Lovenox), can contribute to heavy or prolonged menstrual bleeding.
• Other medical conditions. A number of other medical conditions, including liver or kidney disease, may be associated with menorrhagia.

Some research has found that women with myalgic encephalomyelitis/chronic fatigue syndrome have a higher risk for heavy bleeding ². Women with myalgic encephalomyelitis/chronic fatigue syndrome may experience a range of symptoms that can include fatigue (tiredness or exhaustion that does not get better with rest and sleep), muscle and joint pain, and memory problems.

Risk factors for menometrorrhagia

Risk factors vary with age and whether you have other medical conditions that may explain your menorrhagia. 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.

Menorrhagia in adolescent girls is typically due to anovulation. Adolescent girls are especially prone to anovulatory cycles in the first year after their first menstrual period (menarche).

Menorrhagia in older reproductive-age women is typically due to uterine pathology, including fibroids, polyps and adenomyosis. However, other problems, such as uterine cancer, bleeding disorders, medication side effects and liver or kidney disease must be ruled out.

Menometrorrhagia symptoms

Menometrorrhagia is a combination of metrorrhagia (bleeding between period or intermenstrual bleeding) and menorrhagia (heavy menstrual bleeding).

Signs and symptoms of menorrhagia may include:

• Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
• Needing to use double sanitary protection to control your menstrual flow
• Needing to wake up to change sanitary protection during the night
• Bleeding for longer than a week
• Passing blood clots larger than a quarter
• Restricting daily activities due to heavy menstrual flow
• Symptoms of anemia, such as tiredness, fatigue or shortness of breath

Menometrorrhagia complications

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

• Anemia. Menorrhagia can cause blood loss anemia by reducing the number of circulating red blood cells. The number of circulating red blood cells is measured by hemoglobin, a protein that enables red blood cells to carry oxygen to tissues. Iron deficiency anemia occurs as your body attempts to make up for the lost red blood cells by using your iron stores to make more hemoglobin, which can then carry oxygen on red blood cells. Menorrhagia may decrease iron levels enough to increase the risk of iron deficiency anemia. Signs and symptoms include pale skin, weakness and fatigue. Although diet plays a role in iron deficiency anemia, the problem is complicated by heavy menstrual periods.
• Severe pain. Along with heavy menstrual bleeding, you might have painful menstrual cramps (dysmenorrhea). Sometimes the cramps associated with menorrhagia are severe enough to require medical evaluation.

Menometrorrhagia diagnosis

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 may be evaluated for iron deficiency (anemia) and other conditions, such as thyroid disorders or blood-clotting abnormalities.
• Pap test. In this test, cells from your cervix are collected and tested for infection, inflammation or changes that may be cancerous or may lead to cancer.
• Endometrial biopsy. Your doctor may take a sample of tissue from the inside of your uterus to be examined by a pathologist.
• Ultrasound. 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:

• Sonohysterography. During this test, a fluid is injected through a tube into your uterus by way of your vagina and cervix. Your doctor then uses ultrasound to look for problems in the lining of your uterus.
• Hysteroscopy. This exam involves inserting a thin, lighted instrument through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus.

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.

Menometrorrhagia treatment

Specific treatment for menometrorrhagia is based on a number of factors, including:

• Your overall health and medical history
• The cause and severity of the condition
• Your tolerance for specific medications, procedures or therapies
• The likelihood that your periods will become less heavy soon
• Your future childbearing plans
• Effects of the condition on your lifestyle
• Your opinion or personal preference

Your doctor may try treating heavy bleeding first with hormonal birth control, such as a hormonal IUD ³, the pill, shot, or vaginal ring ⁴. Hormonal birth control is sometimes prescribed by doctors for women’s health concerns other than preventing pregnancy. Your doctor may also suggest trying over-the-counter pain relievers, such as naproxen or ibuprofen, which may lessen bleeding for some women, especially when taken immediately before your period starts or as soon as your period starts.

If birth control or other medicines do not help, you may need surgery to treat the cause of heavy bleeding. Surgery for heavy bleeding is usually the last treatment option women and their doctors consider because surgery always has risks.

Medications

Medical therapy for menorrhagia may include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).
• Tranexamic acid. Tranexamic acid (Lysteda) helps reduce menstrual blood loss and only needs to be taken at the time of the bleeding.
• Oral contraceptives. Aside from providing birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding.
• Oral progesterone. The hormone progesterone can help correct hormone imbalance and reduce menorrhagia.
• Hormonal IUD (Liletta, Mirena). This intrauterine device releases a type of progestin called levonorgestrel, which makes the uterine lining thin and decreases menstrual blood flow and cramping.

If you have menorrhagia from taking hormone medication, you and your doctor may be able to treat the condition by changing or stopping your medication.

If you also have anemia due to your menorrhagia, your doctor may recommend that you take iron supplements regularly. If your iron levels are low but you’re not yet anemic, you may be started on iron supplements rather than waiting until you become anemic.

Procedures

You may need surgical treatment for menorrhagia if medical therapy is unsuccessful. Treatment options include:

• Dilation and curettage (D&C). In this procedure, your doctor opens (dilates) your cervix and then scrapes or suctions tissue from the lining of your uterus to reduce menstrual bleeding. Although this procedure is common and often treats acute or active bleeding successfully, you may need additional D&C procedures if menorrhagia recurs.
• Uterine artery embolization. For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply. During uterine artery embolization, the surgeon passes a catheter through the large artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with materials that decrease blood flow to the fibroid.
• Focused ultrasound surgery. Similar to uterine artery embolization, focused ultrasound surgery treats bleeding caused by fibroids by shrinking the fibroids. This procedure uses ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure.
• Myomectomy. This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
• Endometrial ablation. This procedure involves destroying (ablating) the lining of your uterus (endometrium). The procedure uses a laser, radiofrequency or heat applied to the endometrium to destroy the tissue. After endometrial ablation, most women have much lighter periods. Pregnancy after endometrial ablation has many associated complications. If you have endometrial ablation, the use of reliable or permanent contraception until menopause is recommended.
• Endometrial resection. This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding. Pregnancy isn’t recommended after this procedure.
• Hysterectomy. Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. Hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.

Many of these surgical procedures are done on an outpatient basis. Although you may need a general anesthetic, it’s likely that you can go home later on the same day. An abdominal myomectomy or a hysterectomy usually requires a hospital stay.

When menorrhagia is a sign of another condition, such as thyroid disease, treating that condition usually results in lighter periods.

1. Heavy Menstrual Bleeding. https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
2. Boneva, R.S., Lin, J. M., & Unger, E.R. (2015). Early menopause and other gynecologic risk indicators for chronic fatigue syndrome in women. Menopause, 22, 826–834
3. Espey, E. (2013). Levonorgestrel intrauterine system—first-line therapy for heavy menstrual bleeding. New England Journal of Medicine; 368(2): 184–185
4. Heavy Menstrual Bleeding. https://www.acog.org/Patients/FAQs/Heavy-Menstrual-Bleeding