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Heavy Menstrual Periods: Options for treatment


Medication

With Heavy Menstrual Bleeding, it is important to reiterate the fact that in many patients there will not be any identifiable underlying cause or predisposing factor. Treatment will therefore be generic and tailored to suit her circumstances. What may be offered to a 20 year old college student yet to start a family may differ significantly to a 44 year old mother of teenage children who has long completed her family and is probably already sterilised.


NSAIDs: When we refer to medical treatment we mean using medication to the exclusion of any form of surgery. There are a number of options that fall in this category. One of those is Non-Steroidal Anti-Inflammatory Drugs or NSAIDs. The logic behind deploying NSAIDs for heavy periods is because of their anti-prostaglandin properties. It is a recognised fact that, in menorrhagia, there is often higher than normal levels of prostaglandins that promote blood vessel dilatation thereby increasing blood loss. By using medication with anti-prostaglandin activity, this effect is curtailed. Experience show that, for some women, this medication produces sufficient reduction in menstrual flow thereby solving the problem. However, it is also true that NSAIDs do not work for everybody. Some women barely see any reduction. Moreover, for it to be effective, the medication has got to be used with every period. There is no residual benefit for subsequent periods. The timing is also important. The tablets need to be taken from the time of onset of the period. A delay of even a few hours would normally render the treatment ineffective. The types of NSAIDs that are used for this condition are Mefenamic Acid (brand names Ponstan® and Ponstel®) and Naproxen (brand names Naprosyl®, Feminax Ultra®, Aleve® and many others). Many of these brands are available in many countries without a prescription. NSAIDs used for heavy periods may be a preferred option for women who, apart from heavy loss, suffer from painful periods as well. NSAIDS can be effective in dealing with the pain. These drugs will also be ideal for a woman suffering from heavy periods but who is actively trying to conceive. Other treatment options discussed below, which, by and large, are more effective; are not compatible with a concomitant quest for pregnancy.


Tranexamic acid: This medication works by enhancing the natural clot-formation mechanism thereby helping to stem the heavy bleeding. In many cases of heavy periods, the problem has been identified to be a rapid breakdown of the tiny clots that are formed to plug the broken down blood vessels in the womb cavity. Those clots are the natural mechanism through which menstrual bleeding is limited. Drugs like Tranexamic acid limit the excessive breakdown of those clots therefore aiding the natural mechanism. Such drugs are called ‘anti-fibrinolytic agents’. Tranexamic acid is taken during the period itself starting at the onset. It should not be taken by women with a history of deep vein thrombosis. Women with chronic renal (kidney) disease also ought to exercise caution mainly by reducing the dose. The standard dose is 1g taken four times a day. Tranexamic acid can be safely and effectively combined with NSAIDs discussed above because the two work through different mechanisms.


Hormonal treatment: Hormonal preparations can and are often used to deal with heavy periods. The combined contraceptive pill can be quite effective in sorting out heavy periods. For a woman who does not have contra-indications for the pill and who does not have identifiable risk factors, this is one option that is available to her. This is ideal for a woman who is also in need of an effective and reliable contraceptive.  For a woman who does not need contraception either because she is not sexually active or has another form of contraception already in place, the use of the combined pill solely for dealing with periods could be outside the licence and therefore unavailable. Another commonly used hormonal treatment option is the use of cyclical progestogen tablets. A typical course will involve taking tablets from the fifth day of the cycle and continuing for 21 days. That means the tablets are taken from Day 5 to Day 26 of every cycle. This treatment is quite effective but many women are not enthusiastic about it because of the intense nature of the treatment. This is usually used as a short term measure, not lasting more than a few months. There are many types of progestogen. The type commonly used for this purpose is Norethisterone (also found in the pill Microgynon® and Seasonale®). Another progestogen used is Medroxy-progesterone acetate or MPA (brand names Provera®; Cycrin®; Amen®).  Progestogen medication is sometimes poorly tolerated with problems of feeling bloated, fluid retention and breast tenderness. These preparations, even though not contraceptives in the true sense of the word, would reduce a woman’s chances to conceive during the duration of use (not beyond). They are therefore unsuitable for a sufferer who is actively trying to conceive.


Mirena® IUS: Strictly speaking, this is also a hormonal option. Even though the mode of delivery of the hormone is different from the options described above, Mirena works via the same mechanism. It contains a reservoir of the Levonorgestrel progestogen hormone which is continually released in minute amounts to suppress the lining of the womb from proliferating. This intra-uterine device is extremely effective in dealing with heavy periods. After 6-12 months, menstrual blood loss is reduced by about 96%. Many users attain complete absence of periods (amenorrhoea) in the medium term. It is that good. The device which is roughly the same size as a standard intra-uterine contraceptive device or ‘coil’ is effective for up to 5 years. In addition to this benefit, it is an extremely effective contraceptive; more effective than the contraceptive pill or even female sterilisation. It is therefore quite ideal for a woman suffering from heavy periods but who also wants long term reliable contraception and is probably undecided yet on whether she would want a permanent form of contraception (sterilisation). Mirena is easy to insert, the procedure taking a couple of minutes in a normal clinic setting, is practically devoid of any medium or long term side effects and, more crucially, works for over 90% of users.








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