Causes of a Heavy Period

Heavy menstrual bleeding is a symptom associated with various gynecological disorders, systemic diseases and with the use of certain medication. The presence of other signs and symptoms such as severe menstrual pain, cramping, abnormally large blood clots and any abnormal vaginal discharge should be noted to aid with a diagnosis.

The most common cause of a heavy menstrual bleed is related to hormonal fluctuations. These changes may arise for any number of reasons, either due to underlying gynecological conditions, medication, changes in the body’s physiology or with extreme stress to the system as may be seen after a severe illness. Some of these causes can be transient and may not occur again.

Miscarriage may cause heavy menstrual bleeding. Sometimes a heavy period is experienced by a woman who is not even aware that she is pregnant and is the only symptoms of pregnancy and the subsequent loss of pregnancy. It is the body’s way of expelling the products of conception. Women who are aware of their pregnancy need to be cautious about any bleeding during the first trimester, irrespective of the quantity of blood, as it may be a sign of a threatened abortion or ectopic pregnancy.

Polycystic ovarian syndrome and the start of premature ovarian failure or menopause (perimenopause) may be marked with anovulatory periods. This means that an egg cells is not released from the ovary (anovulation) and can disturb the normal hormonal changes in the menstrual cycle. A heavy period or prolonged period can be a symptom of this disturbance.

Growths in and around the uterus may also cause heavy periods. Uterine fibroids and uterine polyps are benign growths of the uterus. Endometriosis is when the endometrial tissue (inner lining of the uterus) occurs at sites outside of the uterus but usually within the pelvis. The different cancers of the female reproductive tract like ovarian cancer, uterine cancer or cervical cancer very rarely cause excessive vaginal bleeding.

Bleeding disorders are conditions where the normal blood clotting process is affected like in hemophilia or von Willebrand’s disease. This can cause heavy and prolonged menstrual periods.

Medication such as drugs used to alter the hormone levels and anticoagulants specifically may lead to abnormalities of menstrual bleeding. Other medication such as anti-inflammatory drugs may also have this effect. Heavy periods can also occur after using the ‘morning after pill’ (emergency contraceptive) and sometimes after discontinuing birth control pills (oral contraceptive).

Sometimes heavy menstrual bleeding  can be related to other diseases apart from gynecological disorders. This may be seen with thyroid disorders and pelvic inflammatory disease (PID).

Causes of Brown to Black Vaginal Bleeding

It is important to ascertain whether the bleeding is related to a menstrual bleed or not. The presence of other symptoms like pain, discharge preceding or during the bleed, blood clots or pieces of tissue in the blood are all significant in identifying the most likely cause. Remember that a small quantity of brown blood towards the end of a menstrual period is not abnormal and is just degraded blood (“old blood”) being expelled.

Retained menses is not a common phenomenon. It may be due to the menses being retained with the uterus or even in the vagina. An imperforate hymen is where the hymen fully rather than partially covers the vagina and at the onset of menstruation during puberty (menarche), the menses cannot pass out of the vagina. In older women, cervical stenosis which is narrowing of the cervix (or more correctly the endocervical canal) either obstructs or drastically slows down the exit of menses from the uterus. There are other possibly causes relating to anatomical abnormalities of the uterus, cervix or vagina but these are usually present from birth (congenital).

A miscarriage is a more common cause of brown to black vaginal bleeding. While it is a consideration in every pregnant woman’s mind, not all woman realize that they are pregnant until there is an abnormally heavy bleed particularly when it is laden with large clots or the color varies significantly from the normal menstrual blood. The products of conception are eventually ejected but sometimes it is retained. This is known as a missed abortion and arises when the cervical os does not dilate to allow for the products of conception to pass out. Over time there is a scanty brown to black bleed that is often foul smelling. This symptom is less common with an elective / induced abortion if it is done by a medical professional since the cervix is dilated and the products of conception may be removed with a D and C.

Infections of the vagina, cervix or uterus may cause brown to black vaginal bleeds at the proteolytic enzymes of the bacteria rapidly degrade the blood. These infections may be sexually transmitted like gonorrhea and chlamydia, commonly caused by rectal bacteria like E.coli or due to overgrowth of the naturally occurring bacteria in the vagina (vaginosis). It is typically associated with a foul smelling discharge, pelvic pain with pain during urination and intercourse and sometimes a fever.

Cancer is a fairly common cause of vaginal bleeding that is not related to menses – intermenstrual bleeding. It is, however, not a common cause of brown to black vaginal bleeding. An ulceration of the reproductive tract may cause bleeding and if the outflow is restricted or complicated with pelvic inflammatory disease (infection) then there may be a dark brown to black vaginal bleed usually presenting as spotting.

Types of Amenorrhea

Amenorrhea may be classified as primary or secondary. The more common type is secondary amenorrhea where a women with regular menstruation experiences a delay or totally misses a period. It is termed as secondary amenorrhea if more than 3 consecutive periods have been missed in a woman who was otherwise menstruating on a regular basis. In primary amenorrhea, a  girl or young woman has never had a period despite the presence of all the other features of puberty for more than 2 years or with the age advancing beyond 16 years.

The term amenorrhea simply means no period and it normally occurs during pregnancy, during breastfeeding and in menopause. It is not uncommon for the periods to irregular at the onset of puberty, after stopping oral contraceptives, just after pregnancy and as menopause approaches. It is also not abnormal to occasionally miss a single period or sometimes even two periods when ill, with severe psychological stress and immediately after stopping birth control. However, in these cases the period should restore shortly thereafter. If a period is missed on a regular basis though then it needs to be thoroughly investigated to identify the underlying disease.

Amenorrhea is not an indication of ovulation. Sometimes ovulation can occur as normal without menstruation following a short while thereafter. This is known as ovulatory amenorrhea. However, it is more common for ovulation not to occur and this is referred to as anovulatory amenorrhea.

Causes of Missing Periods

Since secondary amenorrhea is more common than primary, the causes focused on here are mainly for women who were having periods previously and have now missed 3 consecutive months. A severe illness particularly a systemic disease may cause secondary amenorrhea even though it may not directly involve the female reproductive tract  since the menstrual cycle is regulated by several outside structures. Women with a very low body weight, particularly those with eating disorders like anorexia nervosa, and those who are obese are more likely to experience amenorrhea. Persistent psychological stress and depression are also more likely to experience secondary amenorrhea. Another non-pathological cause that may lead to amenorrhea is excessive exercising and starvation due to extreme dieting or strict fasting.

Other conditions and diseases which may be responsible for secondary amenorrhea includes :

• Polycystic ovarian syndrome (PCOS)
• Hyperthyroidism or hypothyroidism
• Premature ovarian failure
• Narcotic drug use
• Alcohol abuse
• Pituitary tumors
• Pituitary gland or hypothalamic dysfunction
• Asherman syndrome (scarring of the uterus after surgery or infections)
• Uterine fibroids and polyps
• Cushing’s syndrome
• Diabetes mellitus
• Medication such as antidepressants, antipsychotics, chemotherapy and antihypertensive drugs.

Causes of Menstrual Bloating

Menstrual bloating tends to occur just before and during menstruation. It may start as early as ovulation and persist until the end of menstruation. Abdominal bloating may be a visible and measurable enlargement of the abdomen (distension) with or without a sensation of fullness in the abdomen. It can be associated with other causes particularly gastrointestinal disorders.

In most instances menstrual bloating is functional in nature with evidence suggesting that it may associated with increased intestinal gas and the abnormal passage of this gas.  This does not remove the possibility of fluid retention, particularly if there are additional symptoms like swelling of the feet. However, functional bloating in itself is not clearly understood – neither why it occurs or how it happens.

Not all women experience this bloating and even when it occurs it may not be severe. Instead it may be more likely in women with menstrual irregularity and underlying gynecological disorders like endometriosis and polycystic ovarian syndrome (PCOS). In women who are experiencing secondary amenorrhea, which is the cessation of periods after menarche, there may be monthly bloating around the time of menses although the menstrual period does not occur. It is important to note that a significant distension that appears to be progressing over weeks may not be functional bloating and needs to be medically investigated.

Signs and Symptoms

Abdominal bloating is a symptom. Functional bloating is considered as a functional disorder although it is a not a diseased state. Typically the bloating lasts for just a few days, averaging between 3 days just before and during menstruation. In some women the bloating may start as early as ovulation, or occur at the time of ovulation, resolve and then occur again with menstruation. The bloating, apart from causing discomfort on its own, may also lead to further irritation of the skin as the undergarments or tight clothing may cause pressure and friction when there is  distension.

Treatment of Menstrual Bloating

There is a tendency by many women to use over-the-counter water pills (diuretics) to treat menstrual bloating. This should be avoided as far as possible. If the distension is due to fluid retention then it should be investigated further to identify any disorders associated with the kidneys and electrolyte levels. While a diuretic may help despite the bloating is not due to fluid retention, it is a dangerous practice as the additional fluid and electrolytes are lost unnecessarily and this can lead to dehydration.

Bloating should not be viewed as a symptom on its own but in conjunction with the changes that are occurring in the body at the time of menstruation. It is usually transient and should not be singled out for treatment on its own. Avoiding ‘gassy’ foods and carbonated beverages, exercising and eating smaller meals may all help to minimize bloating. Water should not be avoided because it can actually trigger fluid retention by the kidneys. Looser fitting clothing may reduce the discomfort. Treatment of menstrual irregularities or underlying gynecological disorders may significantly ease bloating along with other menstrual symptoms.

Types of Abnormal Bleeding from the Vagina

There are different terms to describe the various types of vaginal bleeding that are considered to be abnormal.

• Metrorrhagia is the term for any bleed that does not occur at the time of menstruation. It is also known as intermenstrual bleeding.
• Menorrhagia is the term for prolonged menses or excessive.
• Polymenorrhea is the term for too frequent menstruation.

Causes of Abnormal Vaginal Bleeding

There are a host of possible causes and abnormal vaginal bleeding should be investigated further by a medical professional. The site of bleeding can be anywhere in genitourinary system and sometimes bleeding from the urethra is mistaken for a vaginal bleed. Some of the causes include :

• Gynecological Disorders
• Cancer of the vagina, cervix, or uterus
• Cervicitis
• Dysfunctional uterine bleeding (DUB)
• Endometriosis
• Foreign body in the vagina
• Injury of the cervix, vagina, or vulva
• Polyps of the cervix or endometrium (uterus)
• Polycystic ovary syndrome
• Uterine fibroids
• Vaginitis

• Non-Gynecological or Systemic Causes
• Hyperprolactinemia
• Hypothyroidism
• Bleeding disorders
• Medication like hormonal contraceptives and hormone replacement therapy.
• Intra-uterine devices (IUDs)

Pregnant Women

Vaginal bleeding is of greatest concern in pregnancy. It may be a sign of a threatened abortion or ectopic pregnancy if it occurs early in pregnancy. In late pregnancy, vaginal bleeding may be due to abruptio placentae or placenta previa which are very serious conditions that require careful monitoring or medical intervention. Sometimes a bleed in late pregnancy may occur with uterine polyps.

Babies and Young Girls

Vaginal bleeding in children is uncommon. When it does occur it infants it may be due to the estrogens from the mother’s circulation crossing the placenta and is then present in the baby after birth. This can cause vaginal bleeding in infants. In older children, vaginal bleeding should always be investigated first for the possibility of sexual abuse. Other causes may include vaginal or cervical warts, foreign bodies in the vagina or tumors. Sometimes puberty may occur at a much younger age than normal and this is known as precocious puberty.

Some women will experience period pain on its own with no other signs or symptoms. However, there are other symptoms that can sometimes accompany period pain. This may include nausea and/or vomiting, headaches, dizziness, changes in bowel movement and irritability. It is important to have this investigated further as some of these symptoms may be unrelated to menstruation entirely and could be associated with gynecological, pelvic or even systemic diseases.

Location of Period Pain

Most women will experience pain located in the lower abdomen, involving the lower back and extending to the inner thigh. It can sometimes extend outwards to the pelvic bones or even radiate upwards into the central abdomen. The pain is typically described as a cramping or aching pain. Sharper pain may be associated with underlying disorders. Period pain occurs at around the time of menstruation and must be differentiated from mid-cycle pain, also referred to as ovulation pain or Mittelschmerz.

Causes of Period Pain

Dysmenorrhea is a result of cramping in the muscular uterus. Normally there are contractions to facilitate the expulsion of the menses but sometimes these contractions can become painful cramps. It is believed to be due to prostaglandins secreted from the inner uterine lining (endometrium) which causes the muscular layer (myometrium) to contract strongly and also reduces blood flow to the uterus. Period pain that occurs without any underlying gynecological disorder is known as primary dysmenorrhea. However in some cases, the period pain is associated with pathology in the reproductive organs or pelvic cavity. This is then known as secondary dysmenorrhea. Some of the more common causes includes pelvic inflammatory disease (PID), endometriosis and uterine fibroids.

Treatment and Remedies

Certain conservative measures may be sufficient to  reduce and even relieve the period pain. Many women find relief from placing a hot water bottle or heat pad over the lower abdomen. Other measures may involve plenty of rest, eating many small light meals, drinking plenty of fluids, avoiding strenuous activity, using calcium, magnesium or B-complex supplements and even relaxation techniques like yoga or meditation.

However these measures may not be sufficient for every woman suffering with period pain. Medical treatment is therefore advisable. It may involve the use of anti-inflammatory drugs or analgesics (painkillers) – either over-the-counter (OTC) or prescription medication. Oral contraceptives are often recommended particularly in women with menstrual irregularity. Antidepressants may be necessary, not only for depressed women, but also for chronic pain management.

Infertility and Alcohol

The menstrual cycle is a hormonally coordinated process that spans approximately 28 days. Two key events during this cycle is ovulation and menstruation. Any disturbance to the physical and mental health can disrupt the process, even a severe bout of the flu (seasonal influenza). Moderate alcohol consumption, which for women is drinking no more than one unit of alcohol per day, is unlikely to severely impact on the body and therefore disrupt the menstrual cycle. However, many women are drinking more than this and therefore risk disrupting the cycle. This not only includes women who drink more than one unit of alcohol per day, but also women who binge drink even just once a week.

If the menstrual process is disrupted then processes such as ovulation may also be affected. The effects of excessive alcohol consumption are more likely to have an impact on the menstrual cycle and fertility is there is an underlying gynecological or hormonal disorder. Apart from the effects of alcohol on the female body, alcohol misuse can also lead to risky sexual behavior. This increases the chances of contracting sexually transmitted infections which could damage the reproductive organs and further contribute to infertility. Abusing alcohol may also lead to nutritional deficiencies – another possible contributing factor in difficulty conceiving.

Safe Levels of Alcohol Intake for Women

For women who are trying to fall pregnant, abstaining from alcohol may be the best bet. However, safe levels for alcohol consumption in women is about one unit of alcohol per day. Women have a lower body weight than men and this is one reason for the difference between the safe levels in women and men (2 alcoholic units per day). Individual body weight is also a factor and therefore for women with lower body weights, one unit of alcohol may already be a bit high.

Not all alcohol is made equally and a accurate information about the quantities of different alcoholic drinks that constitute one unit needs to be clearly understood. Binge drinking, a more common practice among younger women, is the consumption of three or more drinks at one sitting. Many women are under the misconception that abstaining the entire week allows for additional consumption on the weekend. This is untrue and binge drinking can be as detrimental, if not more so, than drinking slighty more than the recommended daily intake.

Menopause is the time in a woman’s life when her menstrual period starts occurring at longer or irregular intervals, often with less menstrual flow. This is due to a gradual decrease in the levels of the female sex hormones estrogen and progesterone. Eventually, the menstrual period stops altogether. A woman is said to be in menopause when her period has stopped for more than a year. The time leading up to menopause is known as perimenopause, and the time after menopause is complete is known as postmenopause. Many physiological and psychological changes occur in the body, and this is a time of both physical and emotional adjustment in a woman’s life.

Normally, women go through menopause between the ages of 45 and 55. Certain circumstances may bring about early menopause or premature menopause, such as after surgical removal of both the ovaries, which is often done during a hysterectomy (uterus removal) operation. This is known as surgical menopause. Early menopause may also occur due to chemotherapy or anti-estrogen therapy for breast cancer, or due to premature ovarian failure. In such cases the symptoms come on suddenly and may be more severe than in normal menopause due to aging. Once menopause occurs, a woman can no longer fall pregnant.

Signs and Symptoms of Menopause

The symptoms of menopause occur due to fluctuating hormone levels in a woman’s body around that time. This is mainly due to the fact that with age, the ovaries gradually produces less estrogen and progesterone. Menopause symptoms may continue over several years before finally disappearing. However, some women may experience few or no symptoms at all.

The common signs and symptoms are :

• Irregular vaginal bleeding – the periods may come less frequently, with longer intervals in between periods, which may even stretch to a few months. Sometimes, the periods may come at shorter intervals.
• Menstrual flow usually becomes less, but heavy periods may occur. The menstrual flow eventually stops altogether.
• Fertility may decrease around this time but the possibility falling pregnant remains until true menopause occurs, which is the absence of periods for more than a year.
• Hot flashes are one of the most common symptoms of menopause. It is a sudden feeling of warmth over the upper body and face, and may be accompanied by flushing of the skin. Hot flashes may last from 30 seconds to a few minutes and may be followed by sweating. Hot flashes can come any time of the day or night. Although not harmful, they can be distressing, especially when they come several times during the day or night.
• Night sweats may be troublesome in some women.
• Hot flashes and night sweats often lead to sleep disturbances during menopause.
• Headache.
• Palpitation.
• Mood swings, irritability.
• Depression.
• Forgetfulness.
• Tiredness.
• Decreased interest in sex.
• Vaginal dryness, itching, or irritation.
• Dyspareunia or painful sexual intercourse, mainly due to vaginal dryness.

Certain health risks and other features may also develop :

• Increased risk of vaginal infections.
• Urinary problems, such as frequency and incontinence, especially stress incontinence.
• Increased risk of urinary tract infections.
• Joint pain.
• Changes in consistency and shape of the breast.
• Weight gain, with distribution of body fat around the waist and abdomen.
• Thinning of the skin and development of wrinkles.
• Thinning of hair.
• Some women may have hair growth on the chin, upper lip, chest, or abdomen.
• Decreased estrogen levels can cause bone loss which leads to osteoporosis.
• Postmenopausal women are more at risk of heart disease and stroke.

Mittelschmerz is midcycle, one-sided (unilateral), lower abdominal pain which occurs in some women at or around the time of ovulation. Mittelschmerz is a German word. “Mittel” means “middle”, while “schmerz” means “pain”. Ovulation or the release of the ovum (egg) from the ovary usually occurs around day 14 of a 28-day menstrual cycle, which is around the middle of a menstrual cycle, hence the name midcycle pain or ovulation pain. The occurrence of midcycle pain is quite common, particularly in teenagers and older women. Usually mild, in some cases the pain may become quite intolerable.

Cause of Mittelschmerz

The ovaries are situated on either side of the uterus, close to the fimbriated end of the fallopian tubes. There are many primordial follicles present under the ovarian capsule, each containing an immature ovum. At the beginning of each menstrual cycle, several of these follicles start to grow but by about day 6 of the cycle only one of the follicles in one ovary grows to form the dominant follicle.The rest of the follicles disintegrate.

Around the 14th day of the menstrual cycle, the distended follicle ruptures and the ovum is released. This process is known as ovulation. As the ruptured follicle fills with blood, a small amount of the blood from the follicle may escape into the abdominal cavity causing peritoneal irritation. This is the cause of fleeting lower abdominal pain at midcycle, during ovulation, which is known as mittelschmerz.

Another theory is that stretching of the ovarian capsule due to follicular growth is the cause of midcycle pain.

Symptoms of Mittelschmerz

Cramping pain in the lower abdomen and pelvis which may last from a few minutes to several hours. Rarely, the pain may continue for 24 to 48 hours.

• The pain is usually unilateral and may be felt on either side of the abdomen.
• The pain may or may not be on the same side of the abdomen every month.
• Usually occurs during the middle of a menstrual cycle, about 14 days before the next menstrual period.
• The intensity of pain may range from mild to severe.
• Nausea may occur with severe pain.
• The pain may be accompanied by slight vaginal bleeding or spotting.

Diagnosis of Mittelschmerz

The history of the pain is usually indicative of mittelschmerz. No abnormalities are found on physical examination. Ultrasound may be done to rule out other causes of abdominal or pelvic pain. Appendicitis and ectopic pregnancy are the two most important conditions that should be excluded as the cause of pain. Keeping a menstrual diary may help in diagnosis of midcycle pain.

Treatment of Mittelschmerz

There is no specific treatment for mittelschmerz. Simple home remedies such as a warm bath or use of a heating pad on the abdomen may suffice to relieve mild pain. Pain relievers may be used in case of severe pain. Over-the-counter drugs such as acetaminophen (paracetamol), aspirin, or ibuprofen may help. Oral contraceptives or birth control pills may be taken, which will prevent ovulation and thereby reduce or prevent midcycle pain.

Outcome of Mittelschmerz

Mittelschmerz does not lead to any serious complications. It gives an indication of the time of ovulation and may be helpful for women who are trying to get pregnant since this is the most fertile period of the menstrual cycle. It is also an indication that ovulation is taking place.

Ovulation

Follicular Phase

The menstrual cycle starts on the first day of the last menstrual period (LMP) and the first phase continues till ovulation. This initial period is known as the follicular phase. At the start of this phase, the level of the female hormone estrogen is low and this triggers the pituitary gland to secrete a hormone known as follicle-stimulating hormone (FSH). By acting on the ovaries, FSH can then mature the follicles in the ovary. The maturing follicles then start secreting estrogen.

Ovulatory Phase

The presence of this estrogen signals the pituitary gland to secrete another hormone known as luteinizing hormone (LH). The level of LH rises in the bloodstream for a period known as the ovulatory phase. It marks the upcoming event of ovulation. LH acts on the ovaries causing one of the maturing follicles to burst and release an egg cell (ovum). This is known as ovulation. The other maturing follicles disintegrate.

The ovulatory phase and ovulation is marked by certain signs and symptoms that may not be prominent in every woman. However, it can serve as important signals of the best time in a woman’s cycle to fall pregnant. The more reliable of these signs and symptoms includes :

• Changes in cervical mucus where it appears clear and slippery (similar to egg-whites).
• Small rise in body temperature by about 0.4 to 0.6 degrees Farenheit.
• Mild pain or cramping without menstruation which is not always present in every woman.

Menstruation

Luteal Phase

The last phase in the menstrual cycle is known as the luteal phase. It is the time from ovulation till the onset of menstruation (monthly periods). The role of the follicle that has burst and released the egg is not complete once ovulation occurs. Instead the remnants of this follicle, now referred to as the corpus luteum, starts secreting another important hormone known as progesterone. The inner lining of the uterus, known as the endometrium, now needs to prepare for a possible pregnancy and it is the role of progesterone to coordinate this preparation. Should the egg cell be fertilized by a sperm cell from a male, this fertilized egg needs to be nourished and a suitable endometrial structure is needed for its implantation.

Menstruation

However, if fertilization does not occur then the now thickened endometrium is not needed and the entire system has to essentially ‘reset’ itself. The egg cell disintegrates, the endometrial lining is sloughed off and evacuated from the uterus via the vagina (menses). This occurs over a period of 4 to 7 days and is referred to as menstruation. The moment menstruation begins marks the end of the previous cycle and the start of a new cycle.