Blogs & Second Opinion

BLOG 1: WHAT IS HEAVY MENSTRUAL BLEEDING?

Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman’s physical, social or emotional quality of life.

A period is heavy if you are:

• passing lumps of blood (or clots) that are larger than a 50 paise coin
• bleeding so much that you have to change your pad/ tampon every hour
• having to get up most nights to change your pad/tampon
• having to put a towel in your bed or use large maternity pads when you sleep
• bleeding through clothing
• bleeding that lasts more than eight days

Heavy periods can lower your iron levels and red blood cells so you may:

• feel tired more easily
• feel weak or dizzy
• be short of breath and have chest pains.

Heavy periods can generally be managed using hormone therapies or surgery.

Diagnosing what causes heavy periods can sometimes be difficult. However, some physical condition affecting the uterus, such as fibroids and polyps, may cause heavy menstrual bleeding.

The more common reasons for heavy periods are:

• fibroids
• polyps
• endometrial hyperplasia
• endometrial cancer

Fibroids

Fibroids are abnormal growths that form in the muscle of the uterus. They are very common and can occur in up to 80 per cent of women. They are often referred to as ‘tumours’, but the vast majority are not cancerous.

Fibroids are more likely to cause symptoms if they are large, if there are many of them or if they push on your other internal organs. Some women with fibroids have very heavy menstrual bleeding, pelvic pressure or pain that interferes with their life, and some women have problems with fertility and pregnancy. However, fibroid symptoms tend to get better after menopause.

Fibroids can bulge from the inside or outside of the uterus. They can range in size from microscopic to the size of a grapefruit or even larger. The majority of fibroids are small and do not cause any symptoms at all.

Polyps

Uterine polyps are usually non-cancerous (benign) growths of the lining of the uterus (the endometrium). They can also occur at the cervix. Polyps may cause heavy menstrual bleeding, bleeding between periods or bleeding after sexual intercourse. Occasionally, polyps can develop abnormalities, particularly in older women, so it is generally advised to remove them before they become dangerous.

Cancer, malignancy and hyperplasia

Some women may develop an abnormally thick lining of the inside surface of their uterus. This condition is called endometrial hyperplasia and it may cause heavy menstrual bleeding, irregular bleeding or a bloodstained vaginal discharge. In some cases, endometrial hyperplasia may progress to endometrial cancer, a condition that is more common after menopause but can occur in younger women.

Women are at an increased risk of developing endometrial hyperplasia or endometrial cancer if they:

• are over the age of 45 years
• are over 90 kg in weight
• have never had children
• have a family history of endometrial, ovarian or bowel cancer
• have polycystic ovarian syndrome

Adenomyosis

Adenomyosis is a common cause of painful and heavy periods, and can have the same symptoms as endometriosis and fibroids. It occurs when the endometrial glands grow into the muscle of the uterus. As a result, the uterus grows larger, and it can be tender when you are examined. However, it is not easily diagnosed because ultrasound, hysteroscopy, keyhole surgery and magnetic resonance imaging (the common approaches used) will not pick it up all of the time. Women tend to be in their 30s when they are diagnosed.

Other uncommon causes for heavy periods include:

• an underactive thyroid
• the use of anticoagulant drugs
• some liver and kidney conditions
• blood clotting disorders, for example Von Willebrand’s disorder
• using hormone contraception such as the Pill or a prostestogen IUD.

Sometimes a reason for heavy periods is never found. In fact, for nearly half of all women with heavy periods all investigations will show that there is no obvious cause for their bleeding. This is referred to as Dysfunctional Uterine Bleeding and can happen at any age. It is more common in women in their late thirties, which may mean that it is related to hormonal changes as women get older.

Tests for Heavy Menstrual Bleeding:

The gynaecologist will generally do the following:

• ask you questions about the history of your health
• do a blood test
• examine your vagina and cervix, using special tongs (called a speculum). At the same time, they may take a tiny sample of your cervix for testing (called a Pap test)
• take an ultrasound (sonography) of your pelvis.

Further investigations may include a hysteroscopy.

A hysteroscopy uses a long thin telescope or camera (called a hysteroscope) that allows the doctor to see inside the uterus. The hysteroscope can show polyps, fibroids and endometrial thickening. A sample of the endometrium can also be taken for testing.

Treatment

There are a number of treatment options for heavy periods, including medication, surgery and radiology. Your doctor will recommend the best option for you based on your medical history and the reasons for your heavy periods.

Your treatment options will depend on:

• your age, health and medical history
• whether you want to have any (more) children
• how successful other treatments have been for you.

There are three main types of treatment.

• Medication to reduce or control the bleeding and pain. This usually involves taking tablets but sometimes an IUD is placed inside your uterus, which slowly releases the medication into your body.
• Surgery aims to stop the heavy bleeding by removing potential causes like the lining of your uterus (called an endometrial ablation), fibroids in your uterus (called a myomectomy) or your whole uterus (called a hysterectomy).
• Radiology and ultrasound treatments aim to reduce or stop heavy bleeding and pain by reducing and destroying fibroids.

BLOG 2: Causes of repeated pregnancy loss

What is recurrent pregnancy loss?

Recurrent pregnancy loss is defined as having two or more miscarriages. After three repeated miscarriages, a thorough physical exam and testing are recommended.

What is the likelihood of having repeated miscarriages?

A small number of women (1%) will have repeated miscarriages.

What is the most common cause of miscarriage?

Most miscarriages (about 60%) occur randomly when an embryo receives an abnormal number of chromosomes during fertilization. This type of genetic problem happens by chance; there is no medical condition that causes it. However, it becomes more common in women of increased reproductive age.

Are there other genetic problems associated with repeated miscarriages?

In a small number of couples who have repeated miscarriages, one partner has a chromosome in which a piece is transferred to another chromosome. This is called a translocation. People who have a translocation usually do not have any physical signs or symptoms, but some of their eggs or sperm will have abnormal chromosomes. If an embryo gets too much or too little genetic material, it often leads to a miscarriage.

Are problems with reproductive organs associated with repeated miscarriages?

Certain congenital problems of the uterus are linked to repeated miscarriages. Although there are many such disorders, one of the most common that has been associated with miscarriage is a septate uterus. In this condition, the uterus is partially divided into two sections by a wall of tissue.

Asherman syndrome, in which adhesions and scarring form in the uterus, may be associated with repeated miscarriages that often occur before a woman even knows she is pregnant. Fibroids and polyps, which are benign (noncancer) growths of the uterus, also may play a role in recurrent pregnancy loss.

Can medical conditions increase the risk of repeated miscarriages?

Women who have certain medical conditions may have an increased risk of repeated miscarriages. Antiphospholipid syndrome (APS) is an autoimmune disorder in which a person’s immune system mistakenly makes antibodies to certain substances involved in normal blood clotting. APS is associated with repeated miscarriages and fetal deaths. Another disease that can lead to miscarriage is diabetes mellitus . In this disease, high levels of a sugar called glucose are present in the blood. Women with diabetes, especially those in whom the disease is poorly controlled, have an increased risk of pregnancy loss. Women with a condition called polycystic ovary syndrome also have an increased risk of miscarriage.

How common is it that a cause for repeated miscarriages cannot be identified?

In 50–75% of women with repeated miscarriages, no cause can be found for the pregnancy loss. There may be clues about what the problem is, but there is no sure answer.

What tests and exams are available to help find the cause of repeated miscarriages?

To help find the cause of repeated miscarriages, your health care professional will ask about your medical history and past pregnancies. A complete physical exam, including a pelvic exam, may be done. You may have blood tests to detect problems with the immune system. Testing may be done to help detect genetic causes of repeated miscarriages. Imaging tests may be considered to find out if a uterine problem is causing repeated miscarriages.

How common is it that a cause for repeated miscarriages cannot be identified?

In 50–75% of women with repeated miscarriages, no cause can be found for the pregnancy loss. There may be clues about what the problem is, but there is no sure answer.

What tests and exams are available to help find the cause of repeated miscarriages?

To help find the cause of repeated miscarriages, your health care professional will ask about your medical history and past pregnancies. A complete physical exam, including a pelvic exam, may be done. You may have blood tests to detect problems with the immune system. Testing may be done to help detect genetic causes of repeated miscarriages. Imaging tests may be considered to find out if a uterine problem is causing repeated miscarriages.

Is treatment available if the cause of my repeated miscarriages can be identified?

If a specific cause of your repeated miscarriages can be identified, your health care professional may suggest a treatment that addresses the cause.

What can be done if I have a chromosome translocation?

If you have a chromosome translocation, genetic counseling may be recommended. Results of genetic testing can help clarify your options. In vitro fertilization with special genetic testing called preimplantation genetic diagnosis may be done to select unaffected embryos.

How can problems with reproductive organs be treated?

Corrective surgery may be able to increase the chances for a successful pregnancy. For example, a septum in the uterus can be removed.

What treatment is available if I have antiphospholipid syndrome?

Use of a medication that prevents blood clots, such as heparin, sometimes combined with low-dose aspirin, may be prescribed throughout pregnancy and for a few weeks afterward. This treatment can increase the rates of successful pregnancy in women with this condition.

What are my chances of having a successful pregnancy if I have repeated miscarriages and no cause is found?

About 65% of women with unexplained recurrent pregnancy loss have a successful next pregnancy.