Heavy Menstrual Bleeding (Menorrhagia)

A discussion about heavy periods and bleeding disorders

Woman looking out of window
Woman looking out of window. Lilly Roadstones/Creative RF/Getty Images

Say you went to see your gynecologist to see if there is anything you can do about your heavy menstrual bleeding (HMB).  Would you be surprised if your gynecologist wanted you to see a hematologist?  Don't be.  Determining the cause of HMB, also called menorrhagia, can be challenging and may need a multi-disciplinary approach. Seeing both a gynecologist and a hematologist can help in determining if your bleeding is a gynecological problem or a bleeding disorder.

 Additionally, by working together they can determine the best treatment plan for you.  

When your gynecologist says you should also see a hematologist, you might say, "my periods aren't any different than other women in my family and they've never been diagnosed with a bleeding disorder."  Or "all the women in my family have heavy menstrual periods." Although these may be factual statements, they don't necessarily mean you shouldn't be evaluated for a bleeding disorder.  

One of the biggest problems in treating women with HMB is that every woman would define that differently.  Some women might claim their menstrual periods are "normal" when they would meet the definition of HMB.   If all the women in a family have similar heavy menstrual bleeding, the family might label this as "normal" menstrual bleeding when it is not.    

How is heavy menstrual bleeding defined?

Measuring menstrual blood loss is challenging.

 Women have different preferences about how often they change their tampons and/or pads.  Because of these personal differences, physicians needed something more than a tampon/pad count.  There is a scoring system to help determine if a woman has HMB, called the PBAC (pictorial bleeding assessment chart).

 This system uses points to determine if the menstrual bleeding is excessive.  Points are given for the number of tampons/pads used during a cycle with more points are given to fully soaked tampons/pad (1, 5, or 10 points).   Additionally points are given for clots (1 or 5 points) or flooding.  Flooding refers to episodes of overflowing or staining your clothing/underwear.  Your physician might ask you to record this data for one menstrual period to get a better idea of how much blood loss you are experiencing.  If consistent with HMB (score above 100), you may need an evaluation for a bleeding disorder.  

What else might indicate that I have a bleeding disorder?

If you have other bleeding symptoms in addition to HMB, this may indicate you have a bleeding disorder.  This would include prolonged nosebleeds (more than 5 minutes despite appropriate treatment with pressure), gum bleeding, or blood in your urine or stool.  Another symptom might be prolonged bleeding after a cut or lab draw.  

Significant bleeding after an operation may also be a clue that you have a bleeding disorder.  For example, did you have bleeding after tonsillectomy that required intervention (returning to operating room, transfusion, etc)?

 This is dependent on the type of surgery and the risk of bleeding from that surgery.  Your surgeon will have a good idea if your bleeding is unusual.  

Another source of information is your family history.  Do other family members have bleeding issues?  Has someone been labeled a "free bleeder"?  A family history of bleeding plus a personal history of heavy bleeding, strongly suggests a possible bleeding disorder.  The most common bleeding disorder, von Willebrand disease (VWD) is passed down in families and occurs in approximately 1% of the population.  

What sort of work-up should I expect?

The work-up you need is determined by your history and physical examination.

 You may have an ultrasound to determine if there are any structural issues that may be causing HMB, such as uterine fibroid tumors.  Depending on your age, your gynecologist may recommend an endometrial biopsy.  Additionally, blood work may be needed to assess hormone levels.  Assessing your coagulation system (bleeding and clotting) also requires blood work.  This may include work-up for von Willebrand Disease or platelet function disorder.  

If you have concerns about your menstrual bleeding, you should discuss it with your gynecologist or primary care physician.  After assessing your situation carefully, further work-up can be determined.  

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