In clinical practice, patients often come to the clinic because of the number of menstrual periods, among which the number of patients with “menorrhagia” is relatively high. Heavy menstruation is often caused by a disease, but what is the cause of menorrhagia? Does a low menstrual flow mean that menopause is imminent?
1. What is menstruation?
Menstruation is the periodic shedding and bleeding of the endometrium that accompanies the periodic ovulation of the ovaries. The first menstruation is an important sign of puberty, which indicates that the ovaries produce enough estrogen to make the endometrium proliferate, and when estrogen reaches a certain level and fluctuates significantly, it causes the endometrium to shed and menstruation occurs. Therefore, in essence, menstruation is blood.
2. What is normal menstruation?
Menstruation has four basic elements: a menstrual cycle of 21-35 days, with an average of 28 days, and a period of 2-8 days, with an average of 4-6 days. The volume of menstruation is the total blood loss of a menstrual period, normal menstruation is more than 20-60ml, more than 80ml is excessive menstruation.
3.What are the main components of menstruation?
95% of menstrual blood comes from venous and arterial blood, the rest is fluid and cellular debris exuded between tissues, inflammatory cells, cervical mucus and shed vaginal epithelial cells. The color of menstrual blood is dark red. As soon as menstrual blood is produced, it has to be expelled, unless there is an obstruction. There is no reason why there are toxins in the body that need to be expelled from the menstrual blood. Usually, when there are no structural changes, the low menstrual bleeding is not a problem of other blood being “held” somewhere in the body and unable to be expelled. Therefore, in general, if there is no specific organic disease and no fertility requirements, it should not be necessary to treat menorrhagia, while excessive menstrual flow is excessive blood loss and requires active attention.
4.What is excessive menstruation and scanty menstruation?
Excessive menstrual flow of more than 60ml in a menstrual cycle is considered as excessive menstruation and less than 20ml is considered as scanty menstruation. When a patient comes to the clinic with a problem of menstrual flow, the doctor will often ask: “Has your menstrual flow decreased or increased by 1/2 compared to the original? How many sanitary napkins do you use per day? How often do you change one? Do you get each one wet?” When asking a patient with low menstrual flow: “Do you have abdominal pain during your period? Can you wet a sanitary napkin at most? Is it okay to use only pads?” The patient’s answer is highly subjective and it is impossible for the doctor to accurately measure the amount of menstruation, but only to make an approximate assessment based on the patient’s account. An approximate estimate of the amount of sanitary napkins is based on an average of 4-5 changes a day and no more than 2 packs (10 pads) of sanitary napkins per cycle. If more than 3 packs of sanitary napkins are not enough, and almost every sanitary napkin is wet, it is considered excessive menstruation. Therefore, the amount of menstrual flow is often ambiguous, especially for menorrhagia, when the organic disease is not very specific, can only do some relevant examination.
5. Causes of excessive menstruation
Excessive menstruation is often a clinical manifestation of certain diseases, the common diseases are.
Submucosal fibroids: fibroids that grow convexly in the uterine cavity will increase in menstrual flow because the surface of the fibroids is covered with endometrium, which increases the area of the endometrium. In addition, the occupancy of the fibroids in the uterine cavity can affect the discharge of menstrual blood, causing abnormal contractions of the uterus and producing menstrual pain. It often causes anemia and infertility.
Endometrial hyperplasia, endometrial polyp: Due to endocrine disorder, high estrogen level and long-term anovulation in patients, the endometrium proliferates excessively and protrudes into the uterine cavity, smooth, flesh-like hardness, and the length of the tip varies, and the long ones may protrude into the external cervical opening. It often manifests as increased menstrual flow, prolonged periods, dysmenorrhea, infertility, and is diagnosable by ultrasound.
Adenomyosis: The appearance and growth of endometrium in the myometrium is called adenomyosis, which is caused by the increase of estrogen level in the body, resulting in excessive proliferation of endometrium and spreading to the myometrium, which may be triggered by trauma such as pregnancy and childbirth and excessive scraping, and obstruction of the reproductive tract so that menstrual blood cannot be drained outward and the endometrium is extruded into the myometrium. The uterus enlarges and the endometrial area increases; the myometrium becomes hypertrophic, loses its contractility and is unable to control the filling vessels, resulting in more bleeding. It often manifests as: increased menstrual flow, dysmenorrhea, and an enlarged uterus.
Intrauterine device: IUD is a contraceptive device placed in the uterine cavity. It is originally a foreign body, and foreign bodies in the human body can cause mechanical damage to local tissues and chronic inflammation. In particular, the birth control ring containing copper ions is cytotoxic and hemolytic. Clinical manifestations are increased menstrual flow with lumbar and abdominal discomfort.
Inflammation: When there is pelvic inflammation, mainly endometritis, the local blood vessels become fragile, bleeding during menstruation is not easily coagulated and the menstrual flow is often excessive.
Blood system diseases: thrombocytopenic purpura, leukemia, hemophilia, aplastic anemia, etc.
Some drugs: wrongly taking or omitting to take contraceptive pills, etc.
6.Treatment of excessive menstruation
Mainly after symptoms and signs and auxiliary examination, find the primary disease and treat for the primary disease.
Treatment of adenomyosis: for young patients who have not had children, actively promote pregnancy; for young patients who do not have childbearing requirements, apply levonorgestrel intrauterine device to release 20ug levonorgestrel every 24h, valid for 5 years, levonorgestrel can make estrogen receptor synthesis inhibited, indirectly inhibit the proliferation of ectopic endometrium and make it atrophy, reduce bleeding. Hysterectomy is feasible for those who are willing to undergo surgical treatment without fertility requirements.
Endometrial hyperplasia and endometrial polyps: For patients with simple or complex endometrial hyperplasia, medication or levonorgestrel intrauterine device can be applied, see chapter on endometrial lesions for details. For endometrial polyps, hysteroscopic excision of polyps can be applied to prevent recurrence, and levonorgestrel IUD can be applied.
Application of IUD: a small amount of bleeding does not require treatment, the high volume of menstruation is treated with hemostatic application of 6-aminoacetic acid to stop bleeding, remove the IUD when it is ineffective, bleeding for a long time, the application of antibiotics anti-infective treatment.
Inflammation: application of anti-inflammatory drugs for treatment.
Hematologic disorders: If long-term increased menstrual flow is not found to have any cause by gynecologists, consider hematologic examination to exclude hematologic disorders. Refer to hematology for treatment after the diagnosis is confirmed.
7.Why people are more afraid of menorrhagia?
They are afraid that the decrease of menstruation will affect the elimination of toxins in the body, which will lead to chloasma, wrinkles and bags under the eyes, and then gradually amenorrhea, premature aging and premature menopause. They keep asking about the causes of low menstruation and take all kinds of herbs and health products to solve this problem.
8. Causes of menorrhagia
Problems in the discharge channel: The cervical adhesions and cervical adhesions caused by the abortion procedure result in poor flow of menstrual blood, which is manifested as low menstrual flow and accompanied by dysmenorrhea. A history of abortion can be found by following up the medical history.
Endometrial damage: Abortion surgery scrapes the endometrium of the basal layer of the uterus, especially painless abortion, because after intravenous anesthesia, the patient is painless, and often the suction and scraping is too serious, and the endometrium is severely damaged. Some people say that medical abortion is safer and avoids the operation of uterine surgery. However, if the abortion is incomplete, it will prolong the bleeding time, which is not only easy to cause anemia, but also easy to cause infection in the uterine cavity and damage to the endometrium as well when removing the uterine residue. We would like to urge you to use strict contraception when you do not want to have children, because endometrial damage can directly lead to infertility. It is difficult to treat.
Infection with tuberculosis : Infection of the endometrium with tuberculosis can cause damage to the endometrium, resulting in reduced menstrual flow and even amenorrhea. Some patients have had pelvic tuberculosis since childhood, but they are unaware of it and often present to the doctor with primary amenorrhea. These patients have severe damage to the endometrium and have difficulty conceiving despite successful anti-TB treatment.
Hypovarianism: When ovarian function is reduced, estrogen levels decrease, affecting the proliferation of the endometrium and reducing menstrual flow. The diagnosis can be made clearly by measuring FSH, LH and E2.
Endocrine diseases: Hyperprolactinemia, polycystic ovary syndrome and abnormal thyroid function can cause a decrease in menstrual flow or even amenorrhea. The diagnosis can be confirmed by hormone measurement.
Drugs: Taking contraceptive pills and psychiatric drugs can reduce menstrual flow.
9. Treatment of menorrhagia
Cervical and uterine adhesions: separation of adhesions by hysteroscopy, intra-uterine insertion of a birth control device, post-operative estrogen application for 3 months for endometrial repair, and hysteroscopy after 3 months to assess the endometrial condition.
Infection with tuberculosis: diagnosis relies on endometrial biopsy and for patients with tuberculosis if it is active, they should be treated with anti-tuberculosis. Unfortunately, there is no way to make the endometrium grow because the basal layer of the endometrium has been destroyed and the endometrium does not respond to estrogen and no amount of estrogen applied can change the menstrual problem.
Hypovarianism: For patients with reduced menstrual flow due to ovarian hypofunction, there is no way to increase menstrual flow by changing ovarian function, and the ovarian maintenance currently promoted is extremely unscientific. However, we can apply hormone replacement to supplement estrogen to proliferate the endometrium and increase the menstrual flow.
Endocrine diseases: treatment of related diseases is sufficient. Patients with polycystic ovary syndrome can lose weight while applying Daine-35 to lower androgen and restore regular menstruation; patients with hyperprolactin apply bromocriptine to lower prolactin, restore ovulation and resume menstruation.
In conclusion, for patients with reduced menstrual flow with fertility requirements, treatment is based on the etiology, where fertility is difficult to achieve in patients with endometrial tuberculosis and ovarian hypofunction. For patients without fertility requirements, no uterine or cervical adhesions, no endocrine diseases, and normal ovarian function, reduced menstrual flow is not a big problem. Many patients think that menstrual blood can expel toxins, and reduced menstrual flow makes toxins poorly expelled, which affects health and causes facial pigmentation and poor complexion. In fact, menstruation is just a phenomenon, and it does not matter how much. Patients with endometrial tuberculosis without fertility requirements do not need to treat amenorrhea at all as long as their ovaries are functioning normally. In patients with declining ovarian function, any treatment that attempts to correct ovarian function is not helpful, that is, we know that ovarian function is going into decline, but we are powerless to stop it and have to let it progress. However, we can supplement estrogen with hormone replacement to achieve regular menstruation.