Functional Menorrhagia (Heavy Menstruation)

The medical term for a heavy period not related to any other condition (organic pathology) is functional menorrhagia. ‘Functional’ means that the menorrhagia occurs because of disordered function of an otherwise healthy-looking uterus. Women with functional menorrhagia have heavy periods, but their menstrual cycle is normal. The diagnosis implies an absence of identifiable pathology in the reproductive tract such at uterine fibroids or polyps. In addition, cyclic regularity suggests that failure to ovulate is not a cause of the abnormal bleeding.

Why some women have heavier periods than others is not entirely understood. There are a number of common associations with functional menorrhagia, however, that might point to relative oestrogen excess. These include being overweight, a high fat intake, not exercising and stress-induced luteal phase defects. Irregularities in prostaglandins are observed in the endometrium when women have menorrhagia. An imbalance in the prostaglandins levels can occur because of a relative oestrogen excess and/or an excessive saturated fat intake.

One of the prostaglandins, prostacyclin 2, is a potent dilator of blood vessels and also inhibits blood clotting, leading to increased menstrual bleeding.

The medical approach

A diagnosis of functional menorrhagia is a ‘diagnosis of exclusion’ and is made by eliminating all diseases and intrauterine conditions as the reason for the heavy period. Past and present history, Pap smear results, the findings from an internal examination and blood tests may all be necessary in some cases to differentiate between the various causes of the excessive bleeding.

Depending on the age of the woman, a vaginal ultrasound, hysteroscopy or diagnostic D&C is sometimes also suggested if the history of the complaint, the pattern of the bleeding or the age of the woman are suggestive of a pre-cancerous or cancerous condition, or if there is a suspicion of an intra-uterine lesion such as a polyp or fibroid. A D&C is diagnostic rather than therapeutic, although bleeding patterns sometimes return to normal after the procedure. The reasons for this are not always clear. Small sub-mucous fibroids and polyps can be removed during a hysteroscopy.

If there are no obvious causes of the heavy period, a diagnosis of functional menorrhagia is made. The medical practitioner might suggest the following treatments, usually starting at the top of the list and progressing through until a satisfactory outcome is achieved. More details on each of the drugs and surgical procedures is included in ‘Drugs and surgery’.

The Pill

The Pill is a common treatment for menorrhagia and is often the most efficient way to establish a regular cycle and a lighter period.

Prostaglandins inhibitors (Naprogesic, Ponstan)

Prostaglandins inhibitors such as Naprogesic and Ponstan are sometimes used to treat menorrhagia. They block the conversion of prostaglandins into prostacyclin 2 and reduce bleeding, and work best when women are ovulating, or in combination with the Pill or progesterone tablets. Some doctors combine these treatments.

Progestogens in the second half of the month or continually (often Provera or Primolut)

Progestogens are used for menorrhagia even though many women who have this problem do not have irregularities in either progesterone production or hormone balance. When the hormone medication is withdrawn after 10 to 20 days, the endometrium is shed completely and the period often goes back to normal. Progestogens can also be given continuously, which causes the endometrium to shrink.

A Hysteroscopic D&C

This diagnostic procedure allows the gynaecologist to view the uterine cavity, detect any problems and then perform a curette to remove and biopsy abnormally developed endometrium.

Progestogen-releasing IUD

A levonorgestrel-releasing IUD has been used recently in the treatment of abnormal bleeding caused by functional menorrhagia and dysfunctional uterine bleeding. Unlike other IUDs which can increase bleeding, this IUD was found to shrink the endometrium after about three months’ use and many women reported very light periods or amenorrhoea. An additional advantage for sexually active women is that the IUD is a contraceptive device. Women with uterine fibroids and polyps responded less favourably to this type of treatment.

Temporary medically induced menopause

The GnRH agonists (Zoladex, Synarel), which create a ‘medical menopause’, can be suggested for abnormal bleeding which has failed to respond adequately to other methods.

Uterine endometrial ablation

The lining of the uterus (endometrium) is destroyed using laser or cauterisation via a hysteroscope which leads to cessation of, or reduction in, menstruation. A newer method of ablation is the thermal balloon method where the endometrium is destroyed by heat. A balloon is passed through the cervix into the uterus and filled with a glucose solution which is then heated and left in situ for several minutes.

Hysterectomy

The removal of the uterus, which may also involve the removal of the ovaries (hysterectomy and bilateral salpingo-oopherectomy), is reserved as the last treatment option for excessive menstrual loss.

The natural therapist’s approach

Many women visit natural therapists for abnormal bleeding because ‘nothing else has worked’. Often they have been examined by a doctor and told that they just have heavy periods, and that nothing is wrong. When a physical examination has not been performed, the woman should be referred to a doctor for the appropriate examinations. A complete gynaecological check-up is recommended for all women with menorrhagia who are 40 or older, and for any woman who has symptoms which may indicate other conditions.

Once the possibility of other conditions has been eliminated, the first step in a natural therapist’s diagnosis is to determine which categories of herbs will be most likely to reduce menstrual loss for the particular woman to be treated. Anti-haemorrhagic herbs will be a necessity, of course, but often hormone-regulating herbs will be indicated as well. Symptoms such as premenstrual syndrome, an irregular cycle, and spotting or intramenstrual bleeding are suggestive. Taking a basal body temperature reading can also assess whether ovulation is occurring. If there is no evidence of a hormonal irregularity, remedies to regulate hormone levels may not be necessary, even though it is common for medical treatment to include hormones.

Natural therapists can use a variety of clinical assessments to evaluate the causes and the type of treatment they will use for functional menorrhagia. Problems might be confined to the uterus, or be part of a more systemic complaint related to the ‘constitutional state’ of the woman.

Uterine problems might be associated with:

• abnormal uterine tone

• prostaglandins imbalance

• an excess of Heat, Cold or Moistness in the uterus

Or, the bleeding may occur because of an imbalance in the entire system and be caused by:

• nutritional deficiencies

• weakness and lack of vitality leading to a systemic imbalance and (usually) a tendency to become Cold

• liver congestion leading (often) to irritability and headaches, and a tendency to become Hot

In reality, there is considerable overlap in these types of complaints, both in their presentation and treatment. For example, abnormal uterine tissue tone will often occur when there are nutritional deficiencies, particularly iron, and when there is a more generalised lack of vitality. Herbs to nourish Blood and improve vitality often also affect uterine tone (for example, Angelica sinensis); and iron is believed to improve both anaemia and uterine tone.

Nutritional and dietary aspects of functional menorrhagia

Iron

It has been understood for some time that anaemia can be a cause as well as an effect of menorrhagia. Researchers have shown that women who had heavy periods also had depleted iron stores (serum ferritin), but not necessarily anaemia. They speculated that the menorrhagia was caused by a relative weakness of both the uterine muscles and the spiral arterioles of the endometrium which were unable to stop bleeding by contracting. This condition is very similar to the lack of uterine tone described by natural therapists.

Vitamin A

Vitamin A is an important nutrient in the growth and development of adolescents and ensures healthy endometrial growth. Women with normal menstrual loss appear to have significantly better levels of vitamin A than women with menorrhagia. When the women with heavy menstrual loss were given vitamin A, improvement resulted in more than 92 per cent of cases. Normal oestrogen levels are dependent on vitamin A, and a deficiency leads to impaired activity of the enzyme 3 beta-dehydrogenase which is vital to the production of oestrogen (oestradiol).

Vitamin A is only useful for menorrhagia associated with a restricted or inadequate intake. Levels of 10 000 IU for three months are safe (but not for women trying to become pregnant); however, doses of up to 25 000 to 30 000 IU daily have been used and were associated with negligible toxicity. These doses should be supervised. Vitamin A is restricted to 5000 IU tablets for over-the-counter sales and is toxic if taken for prolonged periods.

Vitamin K

Crude chlorophyll has been used historically for excess menstruation, although exactly why it should help has been unclear. One theory is that chlorophyll contains high levels of vitamin K which is necessary for the normal clotting of blood. Vitamin K was shown to reduce the number of menstruating days when menstrual irregularities were associated with longer than normal periods.

Deficiencies of vitamin K are said to be uncommon because dietary intake is usually assumed to be adequate and, anyway, bacterial colonies can manufacture vitamin K in the absence of a good intake. However, the major food source of vitamin K, green leafy vegetables, is often lacking in the average diet and altered bowel flora, especially with the administration of antibiotics, can interfere with normal manufacture of vitamin K. Supplements should not be necessary. A balanced diet containing dark green leafy vegetables and yoghurt should improve any deficiency quickly.

The flavonoids

The flavonoids are a diverse group of compounds which naturally occur in food and medicinal plants, and are some of the major physiologically active constituents of herbal medicines. Flavonoids have diverse effects in the body, several of which may affect menorrhagia. They improve capillary fragility; interact with oestrogen receptor sites, reducing the proliferative effect of oestrogens (phytooestrogens are flavonoids); and inhibit production of oestrogen due to inhibition of the enzyme responsible for its synthesis. But with over 500 different flavonoids identified, it is likely that many of the effects of flavonoids in gynaecological conditions are yet to be discovered.

Flavonoids are commonly found in astringents, plants traditionally used for menorrhagia. This may be related to their affect on capillary fragility. Citrus bioflavonoids reduced the menorrhagia of almost all of the women in one study who were treated with 600 mg of water-soluble bioflavonoid compound. The results were thought to be due to improved capillary strength which reduced permeability and bleeding.

Dietary phyto-oestrogens

Phyto-oestrogens are thought to inhibit the effect of oestrogen on the endometrium by binding to the same receptor sites as endogenous oestrogen. Competitive inhibition by the phyto-oestrogen is responsible for preventing oestrogen from having a stimulatory effect. When menstruating women have a high intake of soya products, studies have shown that they ovulate later, and the period tends to become lighter and shorter.

Prostaglandins and fat intake

Prostaglandins play a major role in the initiation of menstruation and are also involved in menorrhagia and dysmenorrhoea. Prostaglandin inhibitors are used in medicine for the control of bleeding, and it seems likely that some herbs will have similar prostaglandin-inhibiting actions. Manipulating the diet by reducing saturated fats improves menorrhagia. Benefits may arise from the dual effects of a reduction in relative oestrogen excess and improved prostaglandin ratios.

Self care

Exercising and reducing stress levels have many effects on menstrual patterns. These are described in ‘The usual suspects’.

A diet to complement the treatment of functional menorrhagia should reflect the assumed causes. If these are related to iron deficiency, additional iron-containing foods that are also low in fat can be included. A low fat, high fibre diet will reduce menstrual flow by increasing oestrogen clearance and regulating prostaglandin balance. Saturated fats should be avoided or at least reduced. These include those fats found in full-cream dairy products, meat, eggs and some vegetable products, including peanuts and coconut. Fibre also improves oestrogen clearance. Additional information on the effects of fibre and fat on oestrogen levels is included in site.

If bioflavonoid deficiency is the assumed cause of the bleeding, citrus fruits, fruits and vegetables generally, or even buckwheat leaf tea can be taken to correct the problem. But because flavonoids are ubiquitous in the plant world, simply increasing the intake of fruit and vegetables will increase flavonoid intake.

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