What is menorrhagia? How can it affect a woman’s health? What are the common causes of heavy periods? How can they be diagnosed and treated? Discover the answers to these questions and more in our comprehensive guide on heavy menstrual bleeding.

Understanding Menorrhagia: A Deep Dive into Heavy Menstrual Bleeding

Menorrhagia, commonly known as heavy menstrual bleeding, is a condition that affects a significant portion of the female population. Approximately 25% of women experience excessive blood loss during their periods, leading to a range of physical and emotional challenges. In this comprehensive article, we will explore the symptoms, causes, diagnosis, and treatment options for this common gynecological issue.

What Constitutes a “Heavy” Period?

A heavy period, or menorrhagia, is defined as the loss of more than 80ml (about 1/3 cup) of blood during a single menstrual cycle. Telltale signs of a heavy period include:

• Bleeding that lasts longer than seven to eight days
• Frequent “flooding” of pads or tampons, even the largest sizes
• Needing to change pads or tampons every two hours or less
• Passing blood clots larger than a 50-cent piece

It’s important to note that a heavy period should not significantly disrupt your daily activities or cause undue stress and anxiety.

The Impact of Heavy Periods on Women’s Health

Excessive blood loss during menstruation can take a significant toll on a woman’s overall health and well-being. Some of the common effects of heavy periods include:

• Feelings of fatigue, exhaustion, and dizziness
• Pale appearance due to low iron levels (anemia)
• Cramping and pain in the lower abdomen
• Worry and anxiety about potential bleeding incidents

These physical and emotional consequences can severely impact a woman’s quality of life and daily functioning.

Uncovering the Causes of Heavy Menstrual Bleeding

Determining the underlying cause of heavy periods can be a complex process, as there are various potential factors involved. Some of the most common causes of menorrhagia include:

1. Uterine lining overgrowth: In approximately 50% of cases, the endometrium (uterine lining) grows more than usual, leading to increased shedding and blood loss during the menstrual cycle.
2. Hormonal imbalances: Conditions like polycystic ovary syndrome (PCOS) can disrupt the natural balance of hormones, contributing to heavy bleeding.
3. Gynecological disorders: Endometriosis, uterine fibroids, adenomyosis, and endometrial polyps can all cause excessive menstrual bleeding.
4. Pregnancy-related complications: Ectopic pregnancy, miscarriage, or other issues can result in irregular or heavy bleeding.
5. Intrauterine devices (IUDs): In some cases, the presence of an IUD can lead to heavier periods.

It’s important to work closely with a healthcare provider to determine the underlying cause of your heavy periods, as this will guide the most appropriate treatment approach.

Diagnostic Procedures for Heavy Menstrual Bleeding

If you are experiencing heavy or abnormal periods, it is crucial to seek medical attention. Your healthcare provider may perform a variety of tests to diagnose the cause of your heavy bleeding, including:

• Physical examination of the vagina and uterus
• Pregnancy test
• Iron level tests
• Cervical screening tests
• Various blood tests
• Pelvic ultrasound

In some cases, your doctor may refer you to a specialist, such as a gynecologist, if there are indications of underlying conditions like fibroids, adenomyosis, or polyps.

Exploring Treatment Options for Heavy Menstrual Bleeding

The treatment approach for heavy menstrual bleeding will depend on the underlying cause and the individual needs of the patient. Your healthcare provider may recommend a combination of the following options:

• Medication: Hormonal contraceptives, progestin-only medications, or anti-inflammatory drugs may be prescribed to reduce blood loss and regulate the menstrual cycle.
• Intrauterine device (IUD): Certain types of IUDs, such as the hormonal IUD, can help manage heavy periods by reducing blood flow.
• Surgical interventions: In more severe cases, procedures like endometrial ablation or hysterectomy may be recommended to address the underlying cause of the heavy bleeding.

It’s essential to work closely with your healthcare provider to determine the most appropriate treatment plan for your individual needs and preferences.

Seeking Support and Resources for Heavy Menstrual Bleeding

If you are struggling with heavy menstrual bleeding, it’s important to know that you are not alone. There are various resources and support services available to help you navigate this challenge:

• Consult your primary care physician or gynecologist for a comprehensive assessment and personalized treatment plan.
• Reach out to organizations like Jean Hailes for Women’s Health for educational resources and support services.
• Connect with local or online communities of women facing similar experiences to share your story and find solidarity.

Remember, heavy menstrual bleeding is a common condition, and with the right medical care and support, you can take control of your health and improve your quality of life.

Heavy periods – Better Health Channel

Summary

Read the full fact sheet

• Heavy or abnormal periods may be an indication of other health problems.
• About 25% of women lose lots of blood when they have their period.
• Learn more about the effects of heavy periods, the causes, treatment options and where to get help.

About 25% of women lose lots of blood when they have their period. The amount of blood loss from your period can change at different times in your life.

Irregular vaginal bleeding is any bleeding from a woman’s vaginal area and usually refers to bleeding that is not part of a regular period. The range of causes includes infection and hormonal changes. If you suffer from ongoing bleeding problems, see your local doctor for a full assessment to make sure there is no underlying disorder causing the problem.

What is a heavy period?

A heavy period (also called ‘abnormal uterine bleeding’) is when you lose more than 80ml (1/3 cup) of blood each cycle.

Signs of heavy periods include:

• bleeding that lasts longer than seven to eight days
• bleeding or ‘flooding’ of your pad or tampon (especially the largest sizes)
• needing to change your pad or tampon every two hours or less
• needing to change your pad or tampon overnight
• blood clots that are larger than a 50-cent piece.

Your period shouldn’t interrupt your daily activities, or cause stress or anxiety.

Effects of heavy periods

Heavy blood loss from your period can affect you in many ways.

For example, you might:

• feel tired, exhausted or dizzy
• look pale
• have low iron levels
• have cramping and pain in your lower abdomen
• worry that bleeding will soak through your clothes.

What causes heavy periods?

In many cases, it’s hard to know the exact cause of heavy periods. The cause in about 50% of women who have heavy periods is the uterus lining growing more than usual. This lining sheds to create a period.

Other common causes of heavy periods include:

• complications of pregnancy, including ectopic pregnancy or miscarriage
• polycystic ovary syndrome (PCOS)
• endometriosis – when cells similar to those that line the uterus grow in other parts of the body
• endometrial polyps – growths in the inner lining of the uterus
• endometrial cancer
• adenomyosis – when the endometrium grows inside the muscle of the uterus
• fibroids – non-cancerous growths within the uterus wall
• intrauterine device (IUD).

Getting a diagnosis

See your doctor if you are worried about heavy periods.

They might ask about your general health, medical history, sexual activity and plans to get pregnant.

Tests

Your doctor may do some tests to learn more about your heavy periods.

For example, they might do:

• a physical examination of your vagina and uterus
• a pregnancy test
• an iron test
• a cervical screening test
• various blood tests
• an ultrasound.

Your doctor may refer you to a specialist if:

• there is evidence of fibroids, adenomyosis or polyps on your ultrasound
• your bleeding doesn’t improve after six months of treatment.

Treatment options

Treatment options depend on the cause of your heavy periods. Your doctor might prescribe medicine or a change of contraception (for example, an intrauterine device or IUD). They might also suggest surgery for more serious conditions.

For more detailed information, related resources, articles and podcasts, visit Jean Hailes for Women’s HealthExternal Link.

Where to get help

• GP (doctor)
• Gynaecologist
• Family planning clinic
• Sexual Health VictoriaExternal Link. Tel: (03) 9257 0100
• Jean Hailes for Women’s HealthExternal Link

• Hallberg L, Högdahl AM, Nilsson L, Rybo G. Menstrual blood loss – a population study. Variation at different ages and attempts to define normality. Acta Obste Gynaecol Scand. 1966;45(3):320–51.
• Heavy menstrual bleeding; assessment & management. NICE guideline [NG88] www.nice.org.uk/guidance/ng88External Link. March 2018
• Quinn S, Higham J. Outcome measures for heavy menstrual bleeding, Womens Health 2016;(1) 21-26.
• Davies J, Kadir RA. Heavy menstrual bleeding: an update on management. Thromb. Res 2017, 151(1):70-77.
• Kocaoz S, Cirpan R, Degirmencioglu AZ. The prevalence and impacts heavy menstrual bleeding on anemia, fatigue and quality of life in women of reproductive age. Pak J Med Sci. 2019;35(2):365-370. doi:10.12669/pjms.35.2.644.

This page has been produced in consultation with and approved
by:

Vaginal or uterine bleeding: MedlinePlus Medical Encyclopedia

Vaginal bleeding normally occurs during a woman’s menstrual cycle, when she gets her period. Every woman’s period is different.

• Most women have cycles between 24 and 34 days apart. It usually lasts 4 to 7 days in most cases.
• Young girls may get their periods anywhere from 21 to 45 days or more apart.
• Women in their 40s will often notice their period occurring less often.

Many women have abnormal bleeding between their periods at some point in their lives. Abnormal bleeding occurs when you have:

• Heavier bleeding than usual
• Bleeding for more days than normal (menorrhagia)
• Spotting or bleeding between periods
• Bleeding after sex
• Bleeding after menopause
• Bleeding while pregnant
• Bleeding before age 9
• Menstrual cycles longer than 35 days or shorter than 21 days
• No period for 3 to 6 months (amenorrhea)

There are many causes of abnormal vaginal bleeding.

HORMONES

Abnormal bleeding is often linked to failure of regular ovulation (anovulation). Doctors call the problem abnormal uterine bleeding (AUB) or anovulatory uterine bleeding. AUB is more common in teenagers and in women who are approaching menopause.

Women who take oral contraceptives may experience episodes of abnormal vaginal bleeding. Often this is called “breakthrough bleeding.” This problem often goes away on its own. However, talk to your health care provider if you have concerns about the bleeding.

PREGNANCY

Pregnancy complications such as:

• Ectopic pregnancy
• Miscarriage
• Threatened miscarriage

PROBLEMS WITH REPRODUCTIVE ORGANS

Problems with reproductive organs may include:

• Infection in the uterus (pelvic inflammatory disease)
• Recent injury or surgery to the uterus
• Noncancerous growths in the womb, including uterine fibroids, uterine or cervical polyps, and adenomyosis
• Inflammation or infection of the cervix (cervicitis)
• Injury or disease of the vaginal opening (caused by intercourse, infection, polyp, genital warts, ulcer, or varicose veins)
• Endometrial hyperplasia (thickening or build-up of the lining of the uterus)

MEDICAL CONDITIONS

Problems with medical conditions may include:

• Polycystic ovary syndrome
• Cancer or precancer of the cervix, uterus, ovary, or fallopian tube
• Thyroid or pituitary disorders
• Diabetes
• Cirrhosis of the liver
• Systemic lupus erythematosus
• Bleeding disorders

OTHER CAUSES

Other causes may include:

• Use of an intrauterine device (IUD) for birth control (may cause spotting)
• Cervical or endometrial biopsy or other procedures
• Changes in exercise routine
• Diet changes
• Recent weight loss or gain
• Stress
• Use of certain drugs such as blood thinners (Warfarin or Coumadin)
• Sexual abuse
• An object in the vagina
• Effect of low estrogen levels on the vaginal tissue

Symptoms of abnormal vaginal bleeding include:

• Bleeding or spotting between periods
• Bleeding after sex
• Bleeding more heavily (passing large clots, needing to change protection during the night, soaking through a sanitary pad or tampon every hour for 2 to 3 hours in a row)
• Bleeding for more days than normal or for more than 7 days
• Menstrual cycle less than 28 days (more common) or more than 35 days apart
• Bleeding after you have gone through menopause
• Heavy bleeding associated with anemia (low blood count, low iron)

Bleeding from the rectum or blood in the urine may be mistaken for vaginal bleeding. To know for certain, insert a tampon into the vagina and check for bleeding.

Keep a record of your symptoms and bring these notes to your doctor. Your record should include:

• When menstruation begins and ends
• How much flow you have (count numbers of pads and tampons used, noting whether they are soaked)
• Bleeding between periods and after sex
• Any other symptoms you have

Your provider will perform a physical exam, including a pelvic exam. Your provider will ask questions about your medical history and symptoms.

You may have certain tests, including:

• Pap/HPV test
• Urinalysis
• Thyroid functioning tests
• Complete blood count (CBC)
• Iron count
• Pregnancy test

Based on your symptoms, other tests may be needed. Some can be done in your provider’s office. Others may be done at a hospital or surgical center:

• Sonohysterography: Fluid is placed in the uterus through a thin tube, while vaginal ultrasound images are made of the uterus.
• Ultrasound: Sound waves are used to make a picture of the pelvic organs. The ultrasound may be performed abdominally or vaginally. 
• Magnetic resonance imaging (MRI): In this imaging test, powerful magnets are used to create images of internal organs.
• Hysteroscopy: A thin telescope-like device is inserted through the vagina and the opening of the cervix. It lets the provider view the inside of the uterus.
• Endometrial biopsy: Using a small or thin catheter (tube), tissue is taken from the lining of the uterus (endometrium). It is looked at under a microscope.

Treatment depends on the specific cause of the vaginal bleeding, including:

• 
  Hormonal changes
• Endometriosis
• Uterine fibroids
• Ectopic pregnancy
• Polycystic ovary syndrome

Treatment may include hormonal medicines, pain relievers, and possibly surgery.

The type of hormone you take will depend on whether you want to get pregnant as well as your age.

• Birth control pills can help make your periods more regular.
• Hormones also can be given as an injection, a skin patch, a vaginal cream, or through an IUD that releases hormones.
• An IUD is a birth control device that is inserted in the uterus. The hormones in the IUD are released slowly and may control abnormal bleeding.

Other medicines given for AUB may include:

• Nonsteroidal anti-inflammatory drugs (ibuprofen or naproxen) to help control bleeding and reduce menstrual cramps
• Tranexamic acid to help treat heavy menstrual bleeding
• Antibiotics to treat infections

Procedures for AUB may include:

• Endometrial ablation
• Surgical removal of benign growths
• Procedures to block blood supply to uterine vessels
• Hysterectomy

Contact your provider if:

• You have soaked through a pad or tampon every hour for 2 to 3 hours.
• Your bleeding lasts longer than 1 week.
• You have vaginal bleeding and you are pregnant or could be pregnant.
• You have severe pain, especially if you also have pain when not menstruating.
• Your periods have been heavy or prolonged for three or more cycles, compared to what is normal for you.
• You have bleeding or spotting after reaching menopause.
• You have bleeding or spotting between periods or caused by having sex.
• Abnormal bleeding returns.
• Bleeding increases or becomes severe enough to cause weakness or lightheadedness.
• You have fever or pain in the lower abdomen.
• Your symptoms become more severe or frequent.

Aspirin may prolong bleeding and should be avoided if you have bleeding problems. Ibuprofen most often works better than aspirin for relieving menstrual cramps. It also may reduce the amount of blood you lose during a period.

Irregular menstruation; Heavy, prolonged, or irregular periods; Menorrhagia; Polymenorrhea; Metrorrhagia and other menstrual conditions; Abnormal menstrual periods; Abnormal vaginal bleeding

ACOG Practice Bulletin No. 110: Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(1):206-218. PMID: 20027071 pubmed.ncbi.nlm.nih.gov/20027071/.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013;121(4):891-896. PMID: 23635706 pubmed.ncbi.nlm.nih.gov/23635706/.

Bulun SE. Physiology and pathology of the female reproductive axis. In: Melmed S, Auchus, RJ, Goldfine AB, Koenig RJ, Rosen CJ, eds. Williams Textbook of Endocrinology. 14th ed. Philadelphia, PA: Elsevier; 2020:chap 17.

Ryntz T, Lobo RA. Abnormal uterine bleeding: etiology and management of acute and chronic excessive bleeding. In: Gershenson DM, Lentz GM, Valea FA, Lobo RA, eds. Comprehensive Gynecology. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 26.

Seller RH, Symons AB. Menstrual irregularities. In: Seller RH, Symons AB, eds. Differential Diagnosis of Common Complaints. 7th ed. Philadelphia, PA: Elsevier; 2018:chap 20.

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Menopausal uterine bleeding with hormone replacement therapy: the effect of progestogens

According to the Consensus on Hormone Therapy [12], hormone therapy (HT) is most effective for the treatment of vasomotor symptoms during menopause associated with menopause at any age, but at to a greater extent in women under the age of 60 or with a postmenopausal duration of up to 10 years. HT also provides adequate prevention of osteoporosis-related fractures in women with an increased risk of their occurrence before the age of 60 years or within 10 years of menopause. Controversy exists regarding the reduction in the incidence of cardiovascular diseases and the increase in the risk of developing breast cancer when using HT in postmenopausal women [10, 25, 29], although The Framingham study found a positive effect of HT on the cardiovascular system in women with estrogen deficiency during physiological or surgical menopause (T. Gordon et al., 1978). The risk of developing breast cancer in women over 50 associated with HT is a complex issue. It is considered established that the increase in this risk is associated with the addition of progestogen to estrogen therapy and with the duration of treatment. However, the risk of developing breast cancer associated with HT is low and decreases after therapy is discontinued. A decrease in the risk of developing breast cancer in women is associated by some authors with an early shutdown of ovarian function (oophorectomy) (A. Ketcham, W. Sindelar, 1975; L. Brinton et al., 1982).

The risk of developing endometrial cancer is increased in women with an intact uterus using estrogen monotherapy [6, 8], is directly related to the dose of estrogen, duration of therapy and may persist for 10-15 years after stopping treatment [6]. Therefore, in women with a peri- and postmenopausal uterus, the addition of a progestogen to estrogen therapy, known as estrogen-progestogen combination therapy (EPT), is mandatory.

Many observational studies [1, 6] confirm that women taking estrogen plus progestogen at adequate doses have a lower risk of developing endometrial cancer than women who have never taken drugs containing estrogen. Not only in the observational, but also in the prospective, randomized study “Women’s Health Initiative” (WHI) showed a decrease in the incidence of endometrial cancer among women taking HT, compared with the number of diseases in the placebo group (relative risk = 0.81 at 95% confidence interval from 0.48 to 1.36) [2, 18, 29].

There are two main regimens for the use of estrogen-progestogen combination therapy containing different doses of hormones: cyclic regimen (scEPT), in which progestogen is added to the background of continuous estrogen in the last 10-14 days, and continuous combined (estrogen plus progestogen daily) ( ccEPT). The first is intended for women with a preserved uterus in the perimenopausal period, the second – in postmenopause.

In most cases, in perimenopausal women with an intact uterus, the cyclic regimen causes regular monthly bleeding. In contrast, the use of the continuous combination regimen (ccEPT) does not cause monthly uterine bleeding [22, 29]. The addition of a progestogen is required to protect the uterine mucosa from excessive proliferation while taking estrogens.

Thus, the main requirement for the combined regimen of HT is the prevention of the development of intrauterine pathology, in particular, endometrial hyperplasia and cancer [8].

Epidemiological and prospective clinical studies have proven the safety of both HT regimens (scEPT and ccEPT) in terms of increasing the risk of developing hyper- and neoplastic processes in the endometrium in menopausal women [3, 6, 20, 22, 23, 33, 34, 37]. Thus, long-term low-dose oral HT provides reliable endometrial protection.

Regulation of uterine bleeding on the background of HT

Women using a cyclic regimen have a predictable bleeding episode that lasts an average of 4-5 days (D. Archer et al., 1994). According to clinical trials, the lower the dose of estrogen, the lower the frequency of irregular bleeding [4, 7, 30-32]. Many postmenopausal women choose not to have uterine bleeding at all, and continuous combination HT (ccEPT) has been developed for this very purpose [7, 22, 30, 32]. When using this regimen of HT during the first few cycles, the incidence of amenorrhea ranges from 60 to 80% and increases with prolonged use [7, 30-32].

Pathophysiology of bleeding in postmenopausal women on the background of HT

To date, there is no complete understanding of the pathophysiological basis of acyclic uterine bleeding that occurs in postmenopausal women during the use of a continuous regimen of HT. Breakthrough bleeding can occur with both estrogen and estrogen plus progestogen (EPT), although bleeding is more likely with the addition of a progestogen [27-29].

The lining of the uterus (endometrium) is composed of epithelial cells, glandular epithelial cells, a mixture of stromal cells, leukocytes, and an extensive capillary plexus. The reaction of the endometrium to hormonal disorders, both endogenous and exogenous, leads to changes in each of these components. Estrogen and progesterone receptors are present in the intrauterine epithelium, glandular epithelium, stromal and vascular endothelial cells [9, 11, 19, 21]. Each of the components of the endometrium, alone or in combination, can be involved in uterine bleeding. The ultimate cause of bleeding is vascular (capillary) dysfunction. This increases the fragility of the capillaries, which can cause breakthrough bleeding [14]. Factors that could damage the endothelial cell or capillary integrity are believed to play a major role in causing bleeding. There are publications on changes in local intrauterine structures, which may be associated with damage to capillary integrity and vascular permeability in women using HT [15]. During hysteroscopy in women with bleeding while taking progestins, individual focal bleeding areas can be detected [14, 24]. These results of the study confirm local rather than general changes in the intrauterine capillary and nearby tissue, leading to bleeding [14, 24].

There are several possible mechanisms that explain the cause of disorders of the intrauterine capillary bed. One of them – angiogenesis (development of new blood vessels) – is observed during the menopausal transition in women with regular cyclic changes in the uterine mucosa. During the normal menstrual cycle, angiogenesis in the endometrium is regulated by sex hormones (estradiol and progesterone).

In addition, vascular endothelial growth factor (VEGF) and thrombospondin (TSP-1), acting as pro- and antiangiogenic factors, respectively, are important regulators of normal angiogenesis. It is possible that an imbalance of these factors may affect the structure of capillaries and lead to capillary dysfunction, disrupting their integrity, which contributes to increased permeability and/or bleeding of small vessels [26].

The second possible reason is that tissue growth factors involved in hemostasis in the uterine mucosa undergo changes caused by the action of progestogens [24]. This has been proven in targeted biopsies of bleeding areas of the endometrium in women taking progestogen-only birth control. A decrease in tissue growth factor in bleeding areas was found compared to areas with a normal endometrial structure. Most likely, it is this factor that leads to changes in local vascular permeability or the integrity of the uterine vessels and their bleeding.

The third reason is that progestogens are able to suppress the induction of metalloproteinases (MMPs) [35, 36]. Damage to intrauterine MMPs leads to destructuring of the extracellular matrix of the uterine mucosa. MMPs and tissue inhibitors of metalloproteinases (TIMPs) have characteristic endometrial changes in postmenopausal women using HT [38]. Changes in the ratio of MMP to TIMP may indicate a violation of the integrity of the capillary endothelial cell [17].

Finally, it is possible that leukocyte infiltration, especially natural killer cells (uNK), under the influence of the chemotactic effect of progestogen, may be the initiator of bleeding. Natural killer cells have been shown to be associated with a high rate of bleeding in women using a levonorgestrel-containing intrauterine system. Cytokines secreted by the killer cell or stromal cell can lead to changes in the integrity of the capillary bed in the uterine mucosa in postmenopausal women using HT [16].

All of the above are potential pathophysiological links that explain the occurrence of bleeding on the background of HT in general, but they do not explain the cause of bleeding in each individual case. So far, there is no clear evidence of a correlation between local intrauterine change and irregular uterine bleeding. Further large-scale studies are required to fully elucidate the mechanisms involved in the development of uterine bleeding in women receiving HT.

The practitioner has difficulty deciding what to do about unexpected, irregular uterine bleeding in women using HT because the exact cause is not yet known.

Therapeutic interventions

As described above, there is currently no clear pathophysiological mechanism to explain the uterine bleeding that occurs in women taking HT, which is likely due to the individual characteristics of each woman. In this regard, an adequate unified strategy for managing patients with this pathology has not yet been developed. It is obvious that the abolition of HT will lead to the cessation of bleeding.

Practical experience shows that reducing the dose of estrogen reduces the frequency of bleeding [7, 30]. This may be due to the fact that at low doses of estrogen, the number of progesterone receptors in the uterine mucosa is also reduced, which in turn leads to hypoestrogenism and atrophy of the uterine mucosa. This indeed confirms that bleeding occurs secondarily and is due to a complex of mechanisms caused at the local level by the progestogen, which is currently not fully understood. Any approach that reduces the number of progesterone receptors or reduces progestin activity could lead to a reduced risk of bleeding. This may also explain the reduction in bleeding associated with an increase in the dose of progestogen. In turn, this would lead to a reduction in the number of estradiol receptors and would contribute to obtaining histological results of the study, confirming the presence of the uterine mucosa in the atrophy stage (M. Whitehead et al., 1979; M. Whitehead et al., 1981). However, no correlation was found between the result of a histological examination of endometrial scraping from the uterine cavity and the mechanism of uterine bleeding. Currently there is no other successful alternative therapy. There are no practical guidelines to assist the practitioner in determining the appropriate treatment for patients.

A vaginal transducer ultrasound (TVUS) study has shown that uterine echo thickness may be a measure of endometrial status in women using HT, but it does not correlate with the histological findings of endometrial scraping [5]. It is generally accepted that the thickness of the “uterine echo” ≤4.0 mm indicates the absence of pathology in the uterine mucosa in women not taking HT in the postmenopausal period, but this criterion cannot be applied to assess the endometrium in women using HT [13] . In this regard, women receiving HT should be closely monitored by a physician from the start of treatment. In order to assess the cause of uterine bleeding, which is irregular, profuse and prolonged, ultrasound (TVUS), intrauterine biopsy (Pipelle curettage, office or inpatient hysteroscopy) is used. Each patient needs an assessment aimed at identifying the possible cause of the bleeding.

In conclusion, the clinician should be aware that, in the absence of endometrial neoplasia on histological examination, bleeding associated with hormonal therapy is most often due to local changes in the endometrium associated with the use of a progestogen.

How to stop bleeding – EMERCOM of Russia

• Purpose and procedure for performing a general examination of the victim

  The purpose of the physical examination is to identify signs of bleeding that needs to be stopped as soon as possible. A general inspection is carried out very quickly, within 1-2 seconds, from head to toe.

• Main signs of acute blood loss:

  Severe general weakness; feeling of thirst; dizziness; flashing “flies” before the eyes; fainting, more often when trying to get up; pale, moist and cold skin; cardiopalmus; frequent breathing.
  These signs can be observed both in the presence of ongoing external bleeding, and with stopped bleeding, as well as in the absence of visible or ongoing bleeding.

• External bleeding

  Accompanied by damage to the skin and mucous membranes, while the blood is poured out into the environment.

• Arterial bleeding

  They are the most dangerous, since when large arteries are injured, a large loss of blood occurs in a short time. A sign of arterial bleeding is usually a pulsating scarlet stream of blood, a quickly spreading pool of scarlet blood, and the victim’s clothes quickly soaked in blood.

• Venous bleeding

  They are characterized by a lower rate of blood loss, the blood is dark cherry, it flows out in a “stream”. Venous bleeding may be less dangerous than arterial bleeding, but it also needs to be stopped as soon as possible.

• Capillary bleeding

  Observed with abrasions, cuts, scratches. Capillary bleeding usually does not pose a direct threat to life.

• Mixed bleeding

  These are bleedings in which there are simultaneously arterial, venous and capillary bleeding. They are observed, for example, when a limb is torn off. Dangerous due to the presence of arterial bleeding.

• The following methods of temporarily stopping bleeding are currently used in first aid:

  1. Direct pressure on the wound.
  2. Applying a pressure bandage.
  3. Finger pressure of the artery.
  4. Maximum flexion of the limb in the joint.
  5. Applying a hemostatic tourniquet (standard or impromptu).

• Direct pressure on the wound

  Is the easiest way to stop bleeding. When using it, the wound is closed with sterile wipes or a sterile bandage, after which pressure is applied to the wound area by the hand of the first aid participant with sufficient force to stop the bleeding. In the absence of a bandage or napkins, any tissue at hand can be used to apply to the wound. In the absence of personal and improvised means, it is permissible to apply pressure on the wound with the hand of a first aid participant (while not forgetting the need to use medical gloves).
  The victim can also be advised to try to stop the bleeding he has by himself, using direct pressure on the wound.

• Pressure bandage

  A pressure bandage may be used to stop bleeding more permanently. When applying it, you should follow the general principles of applying bandage dressings: it is advisable to put sterile wipes from the first-aid kit on the wound, the bandage should be rolled out in the direction of travel, at the end of the application, the bandage should be fixed by tying the free end of the bandage around the limb. Since the main task of the bandage is to stop bleeding, it must be applied with effort (pressure). If the bandage begins to soak with blood, then a few more sterile napkins are applied over it and bandaged tightly.

• Finger artery pressure

  allows you to quickly and effectively stop bleeding from large arteries. Pressure is applied at certain points between the wound and the heart. The choice of points is due to the possibility of pressing the artery to the bone. The result is a cessation of blood flow to the damaged area of ​​the vessel and a stop or a significant weakening of bleeding. As a rule, digital pressure on the artery precedes the application of a tourniquet and is used in the first seconds after the detection of bleeding and the start of first aid (as well as direct pressure on the wound). Finger pressure on the artery can be either an independent way to stop bleeding, or used in combination with other methods (for example, with a pressure bandage on a wound). The effectiveness and correctness of using this method is determined visually – by reducing or stopping bleeding.

• Compression of the common carotid artery

  The common carotid artery is pressed on the anterior surface of the neck outside the larynx on the side of the injury. Pressure at the indicated point can be carried out with four fingers simultaneously towards the spine, while the carotid artery is pressed against it. Another option for digital carotid pressure is to press the same point with the thumb towards the spine. It is necessary to press with sufficient force, because. bleeding from the carotid artery is very intense.

• Subclavian artery compression

  The subclavian artery is pressed in the fossa above the clavicle against the first rib. You can apply pressure to the pressure point of the subclavian artery using four straightened fingers. Another way to digitally press the subclavian artery is to press with flexed fingers.

• Compression of the brachial artery

  The brachial artery is pressed against the humerus from the inside between the biceps and triceps in the middle third of the shoulder, if the bleeding arose from wounds of the middle and lower third of the shoulder, forearm and hand. Pressure on the pressure point is carried out with the help of four fingers of the hand, clasping the shoulder of the victim from above or below.

• Axillary pressure

  The axillary artery presses against the humerus in the armpit when bleeding from a shoulder wound below the shoulder joint. Pressure on the pressure point of the axillary artery is made with straight, rigidly fixed fingers with sufficient force in the direction of the shoulder joint. In this case, the area of ​​​​the shoulder joint of the victim should be held with the other hand.

• Femoral artery compression

  The femoral artery is pressed below the inguinal fold when bleeding from wounds in the thigh. Pressure is applied with a fist fixed with the second hand, the weight of the first aid participant’s body.

• Maximum limb flexion at the joint

  Maximum flexion of the limb in the joint leads to bending and compression of the blood vessel, which contributes to the cessation of bleeding. This method is quite effective in stopping bleeding. To increase efficiency, 1-2 bandages or rolled-up clothing should be placed in the joint area. After bending, the limb is fixed with hands, several rounds of a bandage or improvised means (for example, a trouser belt).

• Bleeding from wounds of upper arm and subclavian region

  In case of bleeding from wounds of the upper part of the shoulder and the subclavian region, the upper limb is brought behind the back with flexion at the elbow joint and fixed with a bandage, or both hands are brought back with flexion at the elbow joints and pulled together with a bandage.

• Stop bleeding from the forearm

  To stop bleeding from the forearm, a roller is inserted into the elbow bend, the limb is maximally bent at the elbow joint and the forearm is fixed to the shoulder in this position, for example, with a belt.

• Injury to the vessels of the foot, leg and popliteal fossa

  In case of damage to the vessels of the foot, lower leg and popliteal fossa, several bandages or a tissue roller are inserted into the latter, after which the limb is bent at the knee joint and fixed in this position with a bandage.

• Hemorrhage control for hip injury

  To stop bleeding in case of a hip injury, a bundle of tissue or several bandages is placed in the inguinal fold, the lower limb is bent at the hip joint (the knee is pulled to the chest) and fixed with hands or a bandage.

• Applying a tourniquet

  A tourniquet may be used to temporarily stop severe arterial bleeding for longer. To reduce the negative impact of the tourniquet on the limbs, it should be applied in accordance with the following rules.

• Applying a tourniquet

  A tourniquet may be used to temporarily stop severe arterial bleeding for longer.

• To reduce the negative impact of the tourniquet on the limbs, it should be applied in accordance with the following rules.

  1). A tourniquet should be applied only for arterial bleeding in case of injury to the shoulder and thigh.
  2). The tourniquet must be applied between the wound and the heart, as close as possible to the wound. If the place of application of the tourniquet falls on the middle third of the shoulder and on the lower third of the thigh, the tourniquet should be applied higher.
  3). A tourniquet cannot be applied to a naked body, only over clothing or a fabric (bandage) pad.
  4). Before applying, the tourniquet should be wound behind the limb and stretched.
  5). Bleeding is stopped by the first (stretched) round of the tourniquet, all subsequent (fixing) rounds are superimposed so that each subsequent round overlaps the previous one by about half.
  6). The tourniquet should not be covered with a bandage or clothing, i.e. should be visible.
  7). The exact time of applying the tourniquet should be indicated in the note, the note should be placed under the tourniquet
  8). The maximum time the tourniquet is on the limb should not exceed 60 minutes in the warm season and 30 minutes in the cold.
  9). After applying the tourniquet, the limb should be immobilized (immobilized) and thermally insulated (wrapped) using available methods.
  10). If the maximum tourniquet time has expired and medical attention is not available, the following should be done:
  a) carry out digital pressure of the artery above the tourniquet;
  b) remove the tourniquet for 15 minutes;
  c) if possible, perform a light massage of the limb on which the tourniquet was applied;
  d) apply a tourniquet just above the previous place of application;
  e) the maximum reapplying time is 15 minutes.

• As a makeshift tourniquet, you can use improvised means:

  Braid, handkerchief, tie and the like. To stop bleeding in this case, a loop is made from these materials, twisting until the arterial bleeding stops or is significantly weakened using any durable object (metal or wooden rod). When the bleeding is stopped, the rod is bandaged to the limb. Improvised harnesses are also superimposed according to the rules described above.

• If victim is conscious

  It is necessary to seat him with his head slightly tilted forward and pinch his nose in the region of the wings of the nose for 15-20 minutes. In this case, you can put cold on the bridge of your nose. If after the specified time the bleeding has not stopped, you should call an ambulance, until the arrival of which you must continue to perform the same measures.

• If the nosebleed victim is unconscious

  It should be given a stable lateral position, controlling the airway, call an ambulance.

If a casualty is injured, the first aid provider should do the following:

Provide a safe environment for first aid;

Check for signs of life on the victim;

Perform a general examination to determine the presence of bleeding;

Determine the type of bleeding;

Stop bleeding by the most appropriate method or combination.