NEWS | homepage | LIST OF ALL TOPICS | MUM address & What does MUM mean? | e-mail the museum | privacy on this site | who runs this museum?? |
Amazing women! | the art of menstruation | artists (non-menstrual) | asbestos | belts | bidets | founder bio | Bly, Nellie | MUM board | books: menstruation and menopause (and reviews) | cats | company booklets directory | contraception and religion | costumes | menstrual cups | cup usage | dispensers | douches, pain, sprays | essay directory | extraction | famous women in menstrual hygiene ads | FAQ | founder/director biography | gynecological topics by Dr. Soucasaux | humor | huts | links | masturbation | media coverage of MUM | miscellaneous | museum future | Norwegian menstruation exhibit | odor (olor)| pad directory | patent medicine | poetry directory | products, current | religion | your remedies for menstrual discomfort | menstrual products safety | science | shame | slapping, menstrual | sponges | synchrony | tampon directory | early tampons | teen ads directory | tour of the former museum (video) | underpants directory | videos, films directory | Words and expressions about menstruation | Would you stop menstruating if you could? | What did women do about menstruation in the past? | washable pads
More articles by Dr. Soucasaux: Anatomical drawings - Anovulatory cycles - Archetypal aspects of the female genitals - The breasts: some morphological aspects - Colposcopy - Comments on the corpus luteum and related aspects - Comments on some anatomical and symbolic aspects of the female pelvis - The curious relations between androgens and estrogens in women - Drospirenone Oral Contraceptives - Due to prohibition, Brazilian women don't have access to modern medicinal abortion - Endocrinology of menstruation - The Fallopian tubes - Female sexual response - The Gräfenberg Spot (G-Spot) - The Gynecologic Palpation (descendant of "The Touch") - Gynecological assistance: the three basic areas - Gynecology and Gynecologic Surgery - Gynecologist versus obstetrician: what lies behind the combination? - "Gyneco-obstetric-surgical" stubborness and the perpetuation of one of the greatest mistakes of women's medicine - Hypermenorrhea and/or Menorrhagia (Prolonged and/or Excessive Menstrual Bleedings) - Hypertrichosis, Hirsutism and Androgenic Manifestations in Women - Mayer-Rokitansky-Kuster-Hauser (MRKHauser) Syndrome - Menstrual toxin: An old name for a real thing? - Nature and the ovaries - On the Intimate, or Small-Scale, Mechanisms of Menstruation - On the Strange Nature of the Ovaries - Oral hormonal contraceptives (the "Pill") - The Ovaries: Some Functional and Archetypal Considerations - Peculiarities of the Female Genitals' Sensory Innervation - Physiology of menstruation - Polycystic ovaries syndrome - The Possibility of Becoming Pregnant, Its Implications for Women, and Abortion - Premenstrual congestion of the breasts - Premenstrual syndrome (PMS) - The Psychology of Gynecology part 1 (part 2) - Psychosomatic and symbolic aspects of menstruation - Psychosomatic gynecology - Some Details on the Function of the Hypothalamus-Pituitary-Ovaries Axis - Stanislav Grof's Perinatal Matrixes of the Unconscious and Women's Medicine - Symmetric Patterns in the Female Genitals - Thoughts on Female Sexual Psychology - Uninterrupted use of hormonal contraceptives for menstrual suppression: why I do not recommend it - The uterine cervix - Uterine contractility - The Uterus and the Female "Passive-Active" - Women's corporeal consciousness and experience - Women's Experience of the Breasts - Women's Undesired Pregnancies and Women's Right to Abortion and see his Art of Menstruation


Hypermenorrhea and/or Menorrhagia
(Prolonged and/or Excessive Menstrual Bleeding)

Dr. Nelson Soucasaux, Brazilian gynecologist

While in clinical practice the normal duration of the menstrual flow is easy to establish, taking about 3 to 5-6 days, unfortunately the same cannot be said regarding the average amount of the normal menstrual blood loss. This means that, in the daily gynecologic practice, it is the patient who actually tells and "establishes" if the volume of her menstrual flow has increased or is less, and this is done by comparing it with her usual own personal standard. Sometimes there is a rough comparison with the menstrual bleeding of relatives or friends. Thus, there is often a considerable subjectivity in this evaluation. Unfortunately, gynecology has failed to establish a reliable parameter for daily or total blood loss that could be easily applicable to clinical practice. (Maybe an experiment carried out with women who make use of the menstrual cup can help us.) [See also a terrific site to estimate your blood loss: http://www.menstrual-blood-loss.com and read the creator's amusing comments about the site.]

Prolonged and/or excessive menstrual bleedings comprise basically two main groups: the functional and the organic ones. The functional (or dysfunctional) uterine bleedings have their main cause in hormonal or congestive disorders, while the organic ones are mostly caused by fibroid tumors (uterine leiomyomata), polyps and cancer. The association between some excessive and/or prolonged uterine bleedings with some pre-carcinogenic lesions and cancer obliges us to pay attention to all cases of hypermenorrhea and menorrhagia ­ though fortunately most of them are due to entirely benign causes.

Most functional (or dysfunctional) uterine bleeding is caused by hormonal disorders characterized by absolute or relative hyperestrogenism [too much estrogen] due to a deficiency of progesterone. Remember that, in the first phase of the normal ovulatory cycles, the estrogens produce remarkable proliferative effects in the endometrium that are, after ovulation and in the second phase, counterbalanced and opposed by the anti-proliferative and secretory actions of progesterone upon this tissue. As a result, the proliferative estrogenic endometrium is turned into the secretory progesteronic endometrium. Nevertheless, if there is a deficiency of progesterone due to luteal insufficiency or mostly persistent anovulatory cycles (in which there is no progesterone, except in clinically non-significant minimal basal levels), the proliferative and unopposed effect of the estrogens alone will take place along the entire cycle, being able to cause excessive thickening of the endometrium named endometrial hyperplasia. (For luteal insufficiency, see Note 1, below. As to the anovulatory cycles, in which there is no ovulation and no corpus luteum formation, resulting in the absence of progesterone, see my article with the same title published here at the MUM.)

The hyperplastic and excessively thickened endometrium does not desquamate [shed its lining] easily (or even completely) at the end of the cycle, resulting in prolonged and/or excessive menstrual bleedings. In a simplified and didactical way, we can say that, in these hyperplasias, there is "too much endometrium to desquamate" and, therefore, to bleed. In this way, most of the dysfunctional menstrual bleedings are due to endometrial hyperplasias resulting from a persistent estrogenic action upon the endometrium, and this happens mostly as a consequence of anovulation. And, if the anovulatory cycles last longer than the normal duration of the menstrual cycle and the estrogenic production is normal or heightened, the possibility of the development of endometrial hyperplasias becomes greater, together with the occurrence of hypermenorrhea and menorrhagia.

In spite of the frequent occurrence of dysfunctional uterine bleedings throughout the entire women's fertile years, their frequency is greater immediately after menarche and mostly along the years that precede menopause. This is due to the higher incidence of anovulatory cycles (as well as luteal insufficiency) in puberty and pre-menopause. In puberty, anovulatory cycles and the defective luteal phase result from the normal process of maturation of the hypothalamus-pituitary-ovaries axis, whereas in pre-menopause their main cause is just the aging and progressive depletion of the ovaries.

Almost all functional uterine bleeding due to non-complicated endometrial hyperplasias cease with the administration of progestins (synthetic progesterones) alone or associated with estrogens. (Estrogens alone must never be given because they aggravate the hyperplasia, and this must be quite clear.) The use of a progestin like norethysterone in an adequate dose for approximately 10 days usually stops the dysfunctional bleeding in a few days, promoting the secretory transformation of the hyperplastic endometrium and its normal desquamation 3 to 4 days after the end of the series. For preventing the occurrence of further episodes of hypermenorrhea or menorrhagia, the use of almost all progestins (or even natural micronized progesterone) also for approximately 10 days during the second half of the cycle (from the 16th to the 25th day, for instance) is advisable. The use of a combined hormonal oral contraceptive is also indicated, since their balanced synthetic progestin-estrogen association taken in series of 21 days with a 7 days interval between the series prevents the development of endometrial hyperplasias. That's why the use of the combined "Pill" reduces the incidence of endometrial cancer, since some special kinds of endometrial hyperplasias are precursors of this neoplasia.

Conversely, prolonged and/or excessive uterine bleedings due to organic causes, like fibroids, polyps and cancer do not respond to hormones. That means that they do not cease or diminish with hormonal therapy, and this is also a very important test in clinical practice, allowing us to know with a considerable degree of certainty if an abnormal uterine bleeding is due to a functional or an organic cause. Of course, there are exceptions and "in-between" situations.

There are several kinds of hyperplasias of the endometrium, as well as several classifications for them. These endometrial alterations are studied based not only on the histological architecture of the endometrial glands but also on the features of their cells. Basically, for a didactic and practical purpose, endometrial hyperplasia can be typical or atypical. The typical endometrial hyperplasias are the most frequent ones and, fortunately, are histologically benign. They comprehend the simple and the cystic endometrial hyperplasias. On the other hand, the atypical - or adenomatous - endometrial hyperplasias do have an important relationship with the genesis of endometrial cancer. For a long time they were classified in slight, moderate and accentuated atypical hyperplasias of the endometrium. Among them, the accentuated type basically corresponds to the adenocarcinoma in situ of the endometrium (the first stage of endometrial cancer). In this way, the management of typical or atypical endometrial hyperplasias differs a lot. Nevertheless, to speak of the treatment of the atypical endometrial hyperplasias is not the purpose of this article. Endometrial cancer or adenocarcinoma of the uterine corpus is more frequent in women above the age of 50, but also may occur earlier. For that reason, any uterine bleeding in post-menopausal women who are not on hormonal replacement therapy requires immediate and careful investigation.

As to the aforementioned functional congestive disorders that also may cause increased menstrual bleedings, they are related to the pelvic congestion syndrome, characterized by variable degrees of vascular stasis resulting on a persistent engorgement in the female genitals, ligaments and near organs and tissues. There are also other symptoms like pelvic and lumbo-sacral pain and discomfort, and the condition may be due to sexual and psychosomatic problems. The main sexual problem that may cause pelvic congestion seems to be persistent sexual excitement without orgasmic response.

I also must emphasize the great importance of psychosomatic factors in the origin or aggravation of almost all kinds of functional uterine bleedings, hormonal and functional disorders in gynecology. Here, the psychosomatic influences are exerted mostly through the neuroendocrine and neurovegetative pathways, the neuroendocrine being the most important one. As to this subject, see my articles "Psychosomatic Gynecology" and "Psychosomatic and Symbolic Aspects of Menstruation," published here at the MUM.

As to the organic causes for prolonged and/or excessive menstrual bleedings, the most frequent ones are the widely known uterine leiomyomatas or fibroids. Nevertheless, not all kinds of fibroids cause uterine bleedings. In order to cause hypermenorrhea and/or menorrhagia, fibroids must grow towards the uterine cavity, protruding inside it, distorting its shape and/or increasing its size. This causes compressive and congestive alterations in the endometrium, leading to the excessive bleedings. Basically, there are three kinds of fibroids, according to their position in the uterus: the submucous, intramural and subserous ones. Submucous fibroids are the ones that more easily cause uterine abnormal bleedings, because they grow close and towards the uterine cavity, protruding inside it and exerting a direct pressure upon the endometrium. Some of them are even pedunculated [growing on stalks]. Intramural fibroids grow in the middle of the uterine wall and, therefore, need to reach a considerable size in order to protrude inside the uterine cavity and cause the bleedings. Nevertheless, the growth of multiple intramural fibroids may cause a diffuse uterine enlargement accompanied by several distortions and alterations in the shape of the uterine cavity, also resulting in hypermenorrhea and/or menorrhagia. Subserous fibroids are those that grow close and towards the uterine surface, distant from the uterine cavity. For that reason, they do not cause menstrual alterations.

As in all cases of hypermenorrhea and/or menorrhagia due to organic pathologies, abnormal uterine bleedings caused by fibroids do not respond to the use of progestins or progestin-estrogen associations. Nevertheless, there is an exception: cases in which the presence of the fibroids coexist with endometrial hyperplasias due to hyperestrogenism. Cases like these are relatively frequent and, in this way, the intensity of the abnormal bleedings can, at least, be reduced with the use of progestins. This means that, sometimes, cases of excessive menstrual bleeding whose main cause is attributed to existing fibroids actually may have their main origin in hormonal disorders and resulting simple endometrial hyperplasias, which can be treated with progestins.

The treatment of uterine fibroids that undoubtedly are causing abnormal menstrual bleedings (or even other problems, depending on their position and size) unfortunately remains surgical (see Note 2, below. Even so, with the present-day great development of endoscopic surgery (especially the hysteroscopic ones), the operation treatment of fibroids became much more conservative and less invasive and aggressive than in the past. Submucous fibroids, for instance, presently are easily removed with a hysteroscopic surgery, performed by introducing a highly sophisticated endoscopic-surgical-optical device inside the uterine cavity through the vagina. Endometrial polyps, another organic cause of abnormal bleedings, are also easily removed by the same procedure. (As to hysteroscopy, it is also an excellent way of establishing the exact cause of abnormal uterine bleedings, since it allows the observation of the entire uterine cavity at high magnification and, if necessary, to perform a biopsy with precision. Nevertheless, as it is an invasive procedure, in my opinion, as a clinical gynecologist, we only must order a hysteroscopy when it is absolutely necessary.)

Fibroids (or uterine leiomyomata) are very frequent and fortunately benign tumors of the myometrium (the uterine muscular layer). They are formed by a mixture of smooth muscle fibers and fibrous connective tissue and grow into nodules. Their possibility of malignant transformation is extremely low and, for that reason, usually is not considered in clinical practice.

Before finishing I would like to remark that this is only an introductory and very brief article about the extremely complex and intricate subject of the prolonged and/or excessive menstrual bleedings. Because of this and considering not only the limitations of an article written for the Web but also the unimaginable extent and complexity of the subject, this article cannot be regarded as a truly specialized approach to menstrual disorders like hypermenorrhea, menorrhagia and other abnormal kinds of uterine bleeding. Thus, this article is inevitably too, too far from being complete, and I think (and hope) that this is quite obvious to the readers.

Note 1: Luteal insufficiency is a condition in which the production of progesterone by the corpus luteum is deficient. A deficient corpus luteum, though producing low progesterone levels, may last the usual 12 to 14 days or less (7 to 10 days). In the last case, there is a luteal insufficiency due to a short luteal phase.

Note 2: Sadly, the recent attempts at developing a medicinal treatment for uterine fibroids have proved to be disappointing ­ at least on a long-term basis and mostly considering its side-effects. As everybody knows, the growth of fibroids depends on the estrogens, since these hormones are the main responsible factors for the appearance and development of these tumors. That's why the size of fibroids is naturally greatly reduced (and some of them even disappear) after menopause in women who are not on hormonal replacement therapy. Based on this, a medicine named Gn-RH analog was developed in order to promote an intense blockage of the ovarian function resulting in very low estrogen levels (like those existing in natural menopause) and, consequently, in a considerable reduction in the size of fibroids during the treatment. Nevertheless (and obviously), the use of this medicine also produces great genital atrophy and almost all the signs and symptoms of menopause (including even some degree of osteoporosis). For that reason, the treatment with the Gn-RH analog cannot be used for periods of time longer than six months. Despite the great reduction in the fibroids' size obtained during the treatment, a few months after its interruption and due to the subsequent return of the ovarian function to normal, the fibroids grow up again. Because of this, the treatment is only used in a few situations.

Copyright Nelson Soucasaux  2005

______________________________________________

Nelson Soucasaux is a gynecologist dedicated to clinical, preventive and psychosomatic gynecology. Graduated in 1974 by Faculdade de Medicina da Universidade Federal do Rio de Janeiro, Brazil, he is the author of several articles published in medical journals and of the books "Novas Perspectivas em Ginecologia" ("New Perspectives in Gynecology") and "Os Órgãos Sexuais Femininos: Forma, Função, Símbolo e Arquétipo" ("The Female Sexual Organs: Shape, Function, Symbol and Archetype"), published by Imago Editora, Rio de Janeiro, 1990, 1993. He has been working in his private clinic since 1975.

Web site ( Portuguese-English ): www.nelsonginecologia.med.br

Email: nelsons@nelsonginecologia.med.br


NEWS | homepage | LIST OF ALL TOPICS | MUM address & What does MUM mean? | e-mail the museum | privacy on this site | who runs this museum?? |
Amazing women! | the art of menstruation | artists (non-menstrual) | asbestos | belts | bidets | founder bio | Bly, Nellie | MUM board | books: menstruation and menopause (and reviews) | cats | company booklets directory | contraception and religion | costumes | menstrual cups | cup usage | dispensers | douches, pain, sprays | essay directory | extraction | famous women in menstrual hygiene ads | FAQ | founder/director biography | gynecological topics by Dr. Soucasaux | humor | huts | links | masturbation | media coverage of MUM | miscellaneous | museum future | Norwegian menstruation exhibit | odor (olor)| pad directory | patent medicine | poetry directory | products, current | religion | your remedies for menstrual discomfort | menstrual products safety | science | shame | slapping, menstrual | sponges | synchrony | tampon directory | early tampons | teen ads directory | tour of the former museum (video) | underpants directory | videos, films directory | Words and expressions about menstruation | Would you stop menstruating if you could? | What did women do about menstruation in the past? | washable pads
More articles by Dr. Soucasaux: Anatomical drawings - Anovulatory cycles - Archetypal aspects of the female genitals - The breasts: some morphological aspects - Colposcopy - Comments on the corpus luteum and related aspects - Comments on some anatomical and symbolic aspects of the female pelvis - The curious relations between androgens and estrogens in women - Drospirenone Oral Contraceptives - Due to prohibition, Brazilian women don't have access to modern medicinal abortion - Endocrinology of menstruation - The Fallopian tubes - Female sexual response - The Gräfenberg Spot (G-Spot) - The Gynecologic Palpation (descendant of "The Touch") - Gynecological assistance: the three basic areas - Gynecology and Gynecologic Surgery - Gynecologist versus obstetrician: what lies behind the combination? - "Gyneco-obstetric-surgical" stubborness and the perpetuation of one of the greatest mistakes of women's medicine - Hypermenorrhea and/or Menorrhagia (Prolonged and/or Excessive Menstrual Bleedings) - Hypertrichosis, Hirsutism and Androgenic Manifestations in Women - Mayer-Rokitansky-Kuster-Hauser (MRKHauser) Syndrome - Menstrual toxin: An old name for a real thing? - Nature and the ovaries - On the Intimate, or Small-Scale, Mechanisms of Menstruation - On the Strange Nature of the Ovaries - Oral hormonal contraceptives (the "Pill") - The Ovaries: Some Functional and Archetypal Considerations - Peculiarities of the Female Genitals' Sensory Innervation - Physiology of menstruation - Polycystic ovaries syndrome - The Possibility of Becoming Pregnant, Its Implications for Women, and Abortion - Premenstrual congestion of the breasts - Premenstrual syndrome (PMS) - The Psychology of Gynecology part 1 (part 2) - Psychosomatic and symbolic aspects of menstruation - Psychosomatic gynecology - Some Details on the Function of the Hypothalamus-Pituitary-Ovaries Axis - Stanislav Grof's Perinatal Matrixes of the Unconscious and Women's Medicine - Symmetric Patterns in the Female Genitals - Thoughts on Female Sexual Psychology - Uninterrupted use of hormonal contraceptives for menstrual suppression: why I do not recommend it - The uterine cervix - Uterine contractility - The Uterus and the Female "Passive-Active" - Women's corporeal consciousness and experience - Women's Experience of the Breasts - Women's Undesired Pregnancies and Women's Right to Abortion and see his Art of Menstruation