enorrhagia, marked by heavy menstrual bleeding, impacts millions of women worldwide. Its diverse aetiology and varied presentations necessitate comprehensive evaluation. Understanding its complexity is crucial for tailored treatment approaches and enhanced quality of life. Effective management strategies encompass both physical and emotional aspects, aiming for holistic well-being in affected individuals.

The two main risk factors for heavy menstrual bleeding are extremes of age (at menarche and menopause) and obesity. Gynaecological causes include multiple pregnancies which cause the uterus to enlarge gradually resulting in heavy bleeding; reproductive hormone imbalance such as those occurring in Polycystic Ovarian Syndrome; structural abnormalities in the uterus such as fibroids, polyps or adenomyosis; and infections such as pelvic inflammatory disease.

Additionally, certain gynaecological medications such as hormone replacement therapy; oral contraceptives; and intrauterine devices may also cause changes in menstrual bleeding patterns, including heavier periods in certain individuals. Other medications such as blood thinners, chemotherapy medication such as tamoxifen and anti-inflammatory drugs can predispose some individuals to heavy menstrual bleeding.

Research supports a connection between hypothyroidism and menorrhagia emphasising the need for thyroid evaluation in treating heavy menstrual bleeding. Bleeding disorders such as leukaemia, von Willebrand disease or platelet function disorders can also lead to excessive menstrual bleeding.

Menorrhagia is defined as blood loss exceeding 80 ml in a normal cycle surpassing the average of 30 to 40 ml. While occasional heavy periods may not indicate a serious health problem, persistent or severe menorrhagia may require medical attention.

Women with menorrhagia exhibit a range of symptoms, such as soaking through one or more sanitary pads or tampons every hour; passing blood clots larger than 2.5 cm in size; needing to change sanitary pads during the night; bleeding for more than a week; or a combination of heavy periods and pain when passing urine or stools or having sexual intercourse. Due to loss of blood women may feel more tired or fatigued than usual.

Patients should avoid self-medication to prevent potential side effects, seeking professional guidance instead. Treatment to reduce heavy menstrual flow and referral to speciality care must be initiated early to improve the quality of life in this group of patients.

Early consultation with a family physician is essential for those with heavy menstrual bleeding. It enables thorough medical assessment, including detailed medical history, and complete pelvic examination including cervical examination, crucial for ruling out cervical cancer. Moreover, baseline laboratory tests and pelvic ultrasound aid in identifying anaemia, bleeding disorders, thyroid levels and reproductive system abnormalities, enhancing diagnostic accuracy.

The Center for Disease Control and Prevention in the USA provides an assessment tool for menorrhagia to aid in evaluating symptoms and determining appropriate management strategies. Effective management of menorrhagia often involves a combination of approaches, including lifestyle changes; medications; hormonal therapies; or in severe cases, surgical interventions like endometrial ablation or hysterectomy. Lifestyle modifications include iron supplementation; adopting a healthy diet and exercise routine; reducing alcohol intake; and avoiding smoking to improve overall health and well being.

UK guidelines from 2018, updated in 2021, advise initiating pharmacological treatment for heavy menstrual bleeding if low-risk factors such as young age; absence of certain medication use;or medical conditions; and regular menses are present, foregoing investigation into underlying causes. Non-steroidal anti-inflammatory drugs are less effective than tranexamic acid and the levonorgestrel intrauterine system for reducing heavy menstrual bleeding. Women with bleeding disorders have a higher likelihood of undergoing hysterectomy, often at a younger age due to the challenges in managing heavy menstrual bleeding.

Assessing heavy bleeding is crucial. Patients can miss out on sleep, school, work, sports and social events. It is frequently silenced by stigma and misconceptions, despite its common occurrence and substantial influence on women’s well-being. It is essential for individuals experiencing heavy periods to consult with a healthcare provider for proper evaluation and personalised treatment recommendations to address their specific needs and improve their physical and emotional quality of life. Patients should avoid self-medication to prevent potential side effects, seeking professional guidance instead. Treatment to reduce heavy menstrual flow and referral to speciality care must be initiated early to improve the quality of life in this group of patients.

The writer is a family physician