اغلب زنان در دورهای از زندگی خود، خونریزی شدید قاعدگی را تجربه میکنند. بعضی از آنها تقریبا در تمامی دورهها خونریزی شدید دارند. پزشکان اصطلاحا به این خونریزی شدید یا طولانی، «منوراژی» (به انگلیسی: Menorrhagia) (پُردشتانی) یا «هایپرمنوره» میگویند.
با وجود اینکه خونریزی شدید ماهانه در میان زنان در پیش از یائسگی شایع است، تنها درصد کمی از زنان آنقدر زیاد خون دفع میکنند که در حد «منوراژی» باشد. برای اینکه خونریزی ماهانه به حد منوراژی برسد باید حداقل بعضی از علایم زیر را ایجاد کند:
درمان این مشکل بر تشخیص علت استوار است. درمواردی که علت مشخصی یافت نشود استفاده از قرصهای جلوگیری از حاملگی خوراکی و آنتی آندروژنها مانند دانازول مفیدند. در خانمهای سنین بالا میتوان برداشتن رحم را مطرح کرد.
Menorrhagia or hematomunia is an abnormally heavy and prolonged menstrual period at irregular intervals. Menorrhagia can be caused by abnormal blood clotting, disruption of normal hormonal regulation of periods, or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrhea). Fibroids can cause menorrhagia.
A normal menstrual cycle is 21–35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. A blood loss of greater than 80 mL or lasting longer than 7 days constitutes menorrhagia (also called hypermenorrhea). Some authors use menorrhagia exclusively when describing excessive quantity and hypermenorrhea for prolonged duration (although most use both terms interchangeably in the clinical setting). In practice this is not usually directly measured by patients or doctors. Menorrhagia also occurs at predictable and normal (usually about 28 days) intervals, distinguishing it from menometrorrhagia, which occurs at irregular and more frequent intervals. It is possible to estimate the amount of bleeding by the number of tampons or pads a woman uses during her period. As a guide a light tampon will hold 6 mL of blood, a regular tampon will hold 6 to 9 mL of blood, a super tampon will hold 9 to 12 mL of blood, a super plus tampon will hold 12 to 15 mL of blood and an ultra tampon will hold 15 to 18 mL of blood. One may also have lighter cycles in volume, but blood flow may continue more than seven days thus constituting menorrhagia. An OB/GYN should still be consulted.
Usually no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. Most common causes include blood disorder or stress-related disorders. A brief overview of causes is given below, followed by a more formal medical list based on the nature of the menstrual cycle experienced.
Disorders of coagulation
With the shedding of an endometrial linings blood vessels, normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies pfa col/epi can also be used to ascertain platelet function abnormalities
Excessive build-up in endometrial lining
Periods soon after the onset of menstruation in girls (the menarche) and just before menopause may in some women be particularly heavy. Hormonal disorders involving the ovaries-pituitary-hypothalamus (the ovarian endocrine axis) account for many cases, and hormonal-based treatments may effectively regulate such disorders.
The lining of the uterus builds up naturally under the hormonal effects of pregnancy, and an early spontaneous miscarriage may be mistaken for a heavier than normal period.
As women age and move towards menopause, ovulation is delayed and the remaining follicles in the ovaries become resistant to GnRH (Gonadotropin releasing hormone) secreted by the hypothalamus gland in the brain. Either that or they don't develop an egg, and thus no progesterone is produced. Without progesterone, the estrogen is "unopposed" and keeps building up the lining of the uterus.
During a woman's period, the endometrial lining which is normally shed never gets the signal to stop thickening. It keeps growing and sheds irregularly. Due to the extra thickness, the bleeding is unusually heavy. Less frequently in this age group, too little estrogen causes the irregular bleeding. Most cases of hemorrhagic are due to normal hormonal changes preceding menopause.
Irritation of the endometrium may result in increased blood flow, e.g. from infection (acute or chronic pelvic inflammatory disease) or the contraceptive intrauterine device (note the distinction from the IntraUterine System which is used to treat this condition).
Fibroids in the wall of the uterus sometimes can cause increased menstrual loss if they protrude into the central cavity and thereby increase endometriums surface area.
Abnormalities of the endometrium such as adenomyosis (so called "internal endometriosis") where there is extension into the wall of the uterus gives rise to an enlarged tender uterus. Note, true endometriosis is a cause of pain (dysmenorrhoea) but usually not alteration in menstrual blood loss.
Endometrial carcinoma (cancer of the uterine lining) usually causes irregular bleeding, rather than the cyclical pattern of menorrhagia. Bleeding in between periods (intermenstrual bleeding or IMB) or after the menopause (post-menopausal bleeding or PMB) should always be considered suspicious.
Consideration by nature of the menstrual cycle
Where an underlying cause can be identified, treatment may be directed at this. Clearly heavy periods at menarche and menopause may settle spontaneously (the menarche being the start and menopause being the cessation of periods).
If the degree of bleeding is mild, all that may be sought by the woman is the reassurance that there is no sinister underlying cause. If anemia occurs then iron tablets may be used to help restore normal hemoglobin levels.
The condition is often treated with hormones, particularly as dysfunctional uterine bleeding commonly occurs in the early and late menstrual years when contraception is also sought. Usually, oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System (IUS) may be used. Fibroids may respond to hormonal treatment, and if they do not, then surgical removal may be required.
Anti-inflammatory medication like NSAIDs may also be used. NSAIDs are the first-line medications in ovulatory menorrhagia, resulting in an average reduction of 20-46% in menstrual blood flow. For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.
A definitive treatment for menorrhagia is to perform hysterectomy (removal of the uterus). The risks of the procedure have been reduced with measures to reduce the risk of deep vein thrombosis after surgery, and the switch from the front abdominal to vaginal approach greatly minimizing the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids may be dealt with by local removal (myomectomy). A further surgical technique is endometrial ablation (destruction) by the use of applied heat (thermoablation).
In the UK the use of hysterectomy for menorrhagia has been almost halved between 1989 and 2003. This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.
These have been ranked by the UK's National Institute for Health and Clinical Excellence:
Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia. Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration.