Heavy Menstrual Bleeding: Should I Seek a Medical Opinion?

Adenomyosis and endometriosis can cause heavy menstrual bleeding and often occur together. When does anemia from heavy menstrual bleeding turn into a chronic health concern? Can a careful diet help manage anemia? Are there options for surgery?

These are a few of the many questions patients ask when first diagnosed with adenomyosis and endometriosis. Below we will answer each question in depth to help you understand how to best handle each disorder.

What is menorrhagia?

“Heavy” bleeding (menorrhagia) is a common condition among women, defined as >80 ml of blood loss per cycle. Some women struggle for so long with heavy bleeding that they need a blood transfusion either before or during surgery because they have severe anemia.

In a study of university students, 21.8% were found to have menorrhagia, and of these, 14% had a bleeding or clotting disorder, such as von Willebrand disease.

Menorrhagia may also be caused by adenomyosis, a condition in which the endometrium (inner lining of the uterus) grows into the muscular wall of the uterus.

In contrast, endometriosis occurs when the endometrium grows outside the uterus. Both conditions are associated with heavy menstrual bleeding and often occur together.

What causes adenomyosis?

Unfortunately, the precise cause of adenomyosis is not fully understood, and it is one of the more difficult uterine bleeding conditions to diagnose and treat. However, advances in imaging, such as transvaginal ultrasound (TVUS), are making it easier to identify and treat adenomyosis.

The two most prevalent theories about the cause of adenomyosis are:

1. Abnormal growth of the endometrium into the smooth muscle of the uterus (myometrium).
2. Pluripotent cells (immature cells capable of developing into different cell types) are misplaced during early embryo development.

Uterine fibroids (or leiomyomas) are the most common benign tumors, which can also grow into the wall of the uterine muscle. When these tumors are found near the inner surface (submucosa) of the uterus, they can cause heavier bleeding.

How do hormone changes during peri-menopause affect bleeding?

Estrogen and progesterone usually work in concert throughout the cycle, but when ovulation becomes irregular, so do the relative levels of these two hormones.

Estrogen builds up the uterine lining before shedding during menses, but progesterone released after ovulation makes the uterine lining thinner. Before menopause, when ovulation is less regular, estrogen may be higher and progesterone lower.

How is adenomyosis diagnosed?

Your doctor will start with a physical exam of the pelvis to identify enlargement and tenderness, followed by a visual via ultrasound or MRI. If tissues are needed for microscopic review, a hysteroscopy will be performed.

Your doctor may also suggest a blood test to detect anemia and may wish to rule out other reasons for iron-deficient anemia, such as a colonoscopy or fecal blood test for colon cancer.

How much blood loss is normal, and how can I track it?

Menstrual bleeding differs significantly between women. Nevertheless, self-reported blood loss using a menstrual pictogram is considered reasonably reliable. A period tracker app can also help women monitor cycle length and blood loss over several months to establish a pattern.

How many women have menorrhagia?

There is significant variation between women, but the British Journal of Nutrition found the mean blood loss per cycle was 26 ml in a study of 90 healthy women, but 30% of the women were on oral contraceptives and had significantly lower blood loss compared to those not on oral contraceptives.

How do I know if I should seek a medical opinion?

Tracking blood loss, as well as symptoms like clots and flooding can help the doctor provide tailored advice regarding treatment options. Symptoms can include:

• Changing a soaked tampon or pad every 1 to 2 hours.
• Flooding during the night onto the bedding.
• Large clots.
• Planning daily activities around sanitary product changes.
• Exhaustion and pain.

Adenomyosis and anemia

Heavy blood loss can lead to anemia, a deficiency of healthy red blood cells caused by low iron storage (serum ferritin <10 microg/l), with a peak prevalence among women between ages 40-49 and 80-85 years.

Female endurance athletes may have low iron stores due to a combination of menses and foot-strike hemolysis caused by crushing the red blood cells in the feet during long-distance runs.

Foot-strike hemolysis would be unlikely to cause anemia unless the athlete was also experiencing excessive menorrhagia, in which case increasing iron storage might be unusually difficult.

How can I treat anemia and other symptoms of adenomyosis?

Taking ibuprofen can reduce bleeding in approximately 25% of women by reducing prostaglandin production.

Home remedies such as replacing fluids and eating iron-fortified foods can also help. Be sure to check with your doctor before taking an iron supplement, and get enough vitamin C to help with iron absorption when using non-meat foods (or a supplement) for an iron source.

Although taking an iron supplement can help restore your ferritin levels, it is a slow process to rebuild and can cause constipation. Eat enough fruits and vegetables for fiber, and talk to your doctor about the optimal dosing and duration of an iron supplement.

In other words, if supplementing causes such discomfort that you give up, there are other options — supplementing iron every other day may also be sufficient.

On days “off,” look for fortified cereals for breakfast, and remember to drink orange juice. The main concern will be sticking with it and getting blood tests over a year to see if you are trending in the right direction.

What medical options can treat adenomyosis?

Women with adenomyosis may cope by reorganizing their schedules, carefully planning travel, and buying massive supplies of sanitary products to avoid the interruption of life caused by surgery.

However, extreme measures — such as an iron infusion — also have drawbacks, and if your anemia is this severe, it is worth talking to your ob-gyn about the wide array of options available today.

Depending on your stage in life, desire to maintain fertility, and the impact of heavy menses on daily life, you might consider progesterone or progestin therapy to reduce flow, tranexamic acid to bolster the clotting system, and surgical options such as ablation (scraping or scarring the uterine tissue) or hysterectomy (removal of the uterus).

Heavier blood loss than a woman is accustomed to can have a significant impact on quality of life. Even when women are reassured that their measured blood loss is normal, approximately half seek surgery (28%) or medication (18%) for the resolution of their symptoms.

Take time to consult with your doctor

Hysterectomy is the most common medical procedure performed among women in the US, aside from childbirth, but the frequency of hysterectomy is on the decline for women over 40 years old.

Regional variations and insurance are more likely to explain differences in procedure rates, but the trend in declining rates of major surgery may not be altogether bad given the range of non-invasive options available.

Caution in recommending a hysterectomy is warranted and might simply reflect a desire to optimize the risk-benefit ratio for this complex medical condition.

Individualized medicine requires the woman and her doctor to be well-informed about possible adverse events during and after surgery and to participate in shared decision-making after other treatment options have been discussed.