Period Problems
All you need to know about Menorrhagia

Mr Serag Youssif ,
MRCOG England, FRANZCOG Australia

Senior Gynaecologist with Extensive Experience in Gynaecological Surgery

Practicing in Melbourne Victoria  9848 4262
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Menorrhagia is excessive menstrual bleeding in women of reproductive age. The subjective assessment relate how mentrual loss is impacting the woman life style.

Menorrhagia is cyclical heavy menstrual bleeding:

Excessive in both amount and duration
Excessive only in amount
Excessive in duration.

Your heavy Periods may lead to:

Interference with relationships
Interference with hobbies
Iron deficiency anaemia, which can cause tiredness and shortness of breath.

Why the period is heavy?

In the majority of women with menorrhagia, no pathological cause is found i.e Dysfunctional uterine bleeding (ovulatory ie egg is released or anovulatory egg is not released)

This diagnosis is made where there is no pelvic pathology or underlying medical cause identified.

It is better to treat the cause of heavy periods. For example to remove endometrial polyp if diagnosed or to remove fibroid.

How Menorrhagia is Treated:




Nonsteroidal anti-inflammatory drugs (NSAIDs) Mefenamic acid

Antifibrinolytic agents:  Tranexamic acid


Progestogens: Provera, Duphaston and Primolut.

Gonadotrophin-releasing hormone (GnRH) agonists: Goserelin acetate.

Combined oral contraceptive pill 

Levonorgestrel intrauterine system: Mirena insertion appears equally beneficial in improving quality of life and control idiopathic menorrhagia as effectively as conservative surgery (endometrial ablation) over the long term.

Comparing the levonorgestrel intrauterine system with hysterectomy for the treatment of menorrhagia study found that the two treatments do not differ in terms of quality of life, psychosocial wellbeing or satisfaction, with the cost of the levonorgestrel intrauterine system being significantly lower than that of hysterectomy. 

However 42 per cent of the women who used the levonorgestrel intrauterine system (Mirena) to control menorrhagia need hysterectomy within five years.

     Oral medication suits a minority of women in the long term. The benefit of medical therapies is that they enable a woman to maintain her fertility; however, they are often associated with many side-effects.

Do I need Surgery?

If medical therapy fails or is contraindicated or causes intolerable adverse effects surgery is advised.

Sometimes women opt to have surgery as a first-line treatment.

Can I Keep My Uterus?

You can have Endometrial Ablation instead of hysterectomy

What Is Endometrial Ablation?

The lining of uterus, endometrium,  is destroyed by heat, laser or freezing to stop or reduce your periods.

My friend told me that if I have a Curettage my period will be light!
Dilatation and Curettage (D&C) is done to scrape away the uterine lining, endometrium.  The curettage reduces menstrual blood loss immediately but your heavy periods return to previous levels by the second menstrual period. So Curettage is now used for diagnostic purposes only.

First-generation endometrial ablation techniques: endometrial resection, roller ball endometrial ablation, laser endometrial ablation. I all hysteroscopy to look insde the uterus is required.

Second generation endometrial ablation techniques:

If there is a pathological cause of the menorrhagia additional surgical options such as myomectomy or polypectomy may be used.

I was told that I need hysterectomy. What is hysterectomy?
Is the surgical removal of the uterus.

OK I know now that I Want or I Need Hysterectomy will I still have my periods?
No. Hysterectomy has a 100 per cent success rate in stopping your period.

and is associated
with high patient satisfaction.

Is it better to have hystrectomy or Endometrial Ablation?

Hysterectomy is the most common surgical technique for menorrhagia and is the therapy of choice for women with menorrhagia associated with a malignancy. It has a 100 per cent primary success rate and is associated with high patient satisfaction.

Studies comparing hysterectomy and endometrial ablation for heavy menstrual bleeding found that hysterectomy guarantees permanent relief from heavy menstrual bleeding; however, it is associated with a longer operating time, longer recovery period, higher rates of postoperative complications, and increased cost.

Over 20 per cent of the women who have hysterectomies performed for non-malignancy in Australia experience complications prior to hospital discharge. This rate of complications represents all complications which occur in women who undergo a hysterectomy, including very minor complications and complications which occur during the hospital stay that are unrelated
to the surgical procedure.

First-generation endometrial ablation techniques

Since the early 1980s, more conservative surgical approaches have been developed as
alternatives to hysterectomy for women with menorrhagia. First-generation techniques
involve using a hysteroscope and a fluid distension medium to enable visualisation of the
uterine cavity during surgery. The first-generation procedures are outlined at the
beginning of this background section.

Second-generation endometrial ablation techniques

Are newer nonhysteroscopic (except for hydrothermal ablation) techniques.

Microwave endometrial ablation (MEA)

Thermal balloon endometrial ablation (TBEA)

Radiofrequency electrosurgery

Hydrothermal ablation


Endometrial thermal intrauterine thermotherapy

Radiofrequency balloon

The radiofrequency balloon is similar to the thermal balloon (described at the beginning
of this background section); however, heated electrodes are used rather than heated
liquid to ablate the endometrium. The balloon is inflated using air, bringing the
electrodes into contact with the endometrium. The Vesta RF balloon has
12 radiofrequency electrodes which are heated to between 70 and 75 °C for 4 minutes
using 45 watts of power (Isaacson 2001). The lowest temperature is used in the cornual
regions where the uterine wall is thinnest. The Vesta RF balloon, while listed on the
Australian Register of Therapeutic Goods, is no longer marketed in Australia.

Photodynamic endometrial ablation

Photodynamic endometrial ablation uses the topical administration of a photosensitising
drug onto the endometrium. Light activation with a diffusing fibre tip placed in the
uterine cavity causes light-induced oxidation reactions, which then cause tissue necrosis.
The technique of photodynamic endometrial ablation is very new, and a recent
morphological study in which 4 women underwent photodynamic endometrial ablation
using 5-aminolevulinic acid (ALA) prior to hysterectomy found that necrosis including
the full thickness of the endometrium was found 3 days after the procedure

Other surgical techniques

For women who have pathological causes of menorrhagia such as fibroids and polyps,
surgery to remove the intrauterine pathology may reduce menstrual blood loss. Examples
of such operations are a myomectomy (surgery to resect the myomata or fibroids) or a
polypectomy (surgery to resect polyps). These operations, if performed without
endometrial ablation, may reduce the menstrual bleeding (if the pathology was the cause
of the menorrhagia), and enable a woman to maintain her fertility.

Causes of menorrhagia  ie Heavy periods
Systemic in the body but not in ovary or uterus Local in ovary or uterus Iatrogenic: caused by doctors
Systemic coagulopathy (eg von
Willebrand’s disease) ie
Hereditary deficiency in clotting

Endometrial adenocarcinoma


Intrauterine device (copper)

Anovulatory dysfunctional
uterine bleeding

Uterine fibroids (leiomyomas)

Excessive anti-coagulation ie
Exessive blood thining drugs

Endometrial hyperplasia
ie different looking cells

Endometrial polyps
  Ovulatory dysfunctional
uterine bleeding