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What is menorrhagia?

Menorrhagia is a heavy or prolonged menstrual bleeding. Many women have this type of abnormal uterine bleeding. It can be related to a number of conditions including problems with the uterus, hormone problems, or other rare conditions. While heavy bleeding can make it tough to take part in normal daily life at times, there are treatments to help.

What causes menorrhagia?

During your menstrual cycle, if an egg is not fertilized, the uterine lining breaks down, and bleeds. The egg and the uterine lining are then shed during your period.

Hormone problems or conditions that affect the uterus can result in heavy bleeding. Other diseases or bleeding disorders can also cause it.

Hormone problems include:

• Imbalance of estrogen and progesterone or other hormones

Problems with the uterus include:

• Fibroids (non cancerous)
• Cancer
• Pregnancy problems (such as a miscarriage or ectopic pregnancy)
• Use of an intrauterine device (IUD)

Other conditions such as thyroid, kidney or liver disease, cancer or bleeding disorders can also cause heavy bleeding.

What are the symptoms of menorrhagia?

If you have to change your pad or tampon every 1 to 2 hours because it is soaked, or bleed longer than 7 days, see your doctor. Spotting or bleeding between periods is also a sign of a problem.

The symptoms of menorrhagia may look like other conditions or medical problems. Always consult your healthcare provider for a diagnosis.

How is menorrhagia diagnosed?

Your healthcare provider will ask you about your medical history and about your periods. You will also have a physical exam including a pelvic exam. You may be asked to keep track of your periods and how many pads or tampons you use for a few months if you haven’t already done so.

• Blood tests. These check for anemia and test how fast your blood clots.
• Pap test. For this test, cells are collected from the cervix and examined. It’s used to check for cancerous changes, infection, or inflammation.
• Ultrasound. Using sound waves and a computer, your healthcare provider can check for fibroids or other problems inside the uterus.
• Biopsy. Examining a tissue sample from the uterine lining can help your healthcare provider find cancer or other abnormal tissue.

Other tests include:

• Hysteroscopy. Using a viewing instrument inserted through the vagina, your healthcare provider can see the cervix and the inside of the uterus.
• Dilation and curettage (D&C).This procedure involves scraping and then examining the uterine cavity.

Treatment

Treatment of menorrhagia depends on the individual case.

Drug therapy includes:

• Iron supplements to treat anemia
• Tranexamic acid, or Lysteda, taken at the time of bleeding to help reduce blood loss
• Oral contraceptives to regulate the menstrual cycle and decrease bleeding duration and quantity
• Oral progesterone to treat hormonal imbalance and reduce bleeding
• Hormonal IUD to thin the lining of the uterus, reducing bleeding and cramping

In women who have a bleeding disorder, such as von Willebrand’s disease or mild hemophilia, Desmopressin nasal spray, or Stimate can boost the levels of blood-clotting proteins.

Nonsteroidal anti-inflammatories, such as ibuprofen, or Advil, can be used to treat dysmenorrhea, or painful menstrual cramps, and they can help reduce blood loss. However, NSAIDS can also increase the risk of bleeding.

Surgical interventions

A number of surgical procedures are available to treat or relieve the symptoms of menorrhagia.

• Dilation and curettage (D&C) is a surgical procedure for scraping the lining of the uterus
• Uterine artery embolization treats fibroids, a cause of menorrhagia, by blocking arteries that feed them
• Hysteroscopy involves inserting a camera into the uterus to evaluate the lining, assisting in the removal of fibroids, polyps, and the uterine lining.
• Focused ultrasound ablation uses ultrasonic waves to kill fibroid tissue.
• Myomectomy is a surgical intervention to remove uterine fibroids through several small abdominal incisions, an open abdominal incision, or through the vagina.
• Endometrial ablation permanently destroys the lining of the uterus.
• Endometrial resection uses an electrosurgical wire loop to remove the uterine lining.
• Hysterectomy removes the uterus and cervix, and, sometimes, the ovaries.

The choice of intervention will take into account the cause and extent of the condition, the age and health of the patient, and their personal preference and expectations.

Dr.Ruchi Tandon is a Gynecologist practicing in leading hospitals in South Delhi and Greater Kailash.

What is stress incontinence?

Stress incontinence is the inability to control your urge to urinate in certain circumstances. It’s a serious and embarrassing disorder and can lead to social isolation. Any pressure placed on the abdomen and bladder can lead to the involuntary loss of urine.

It’s important to remember that the term “stress” is used in a strictly physical sense when describing stress incontinence. It refers to excessive pressure on the bladder and not emotional stress.

An overactive bladder is a separate condition. In some cases, both overactive bladder and stress incontinence can occur, which is called mixed incontinence. Your Gynecologist can do tests to determine which is causing your incontinence.

Anatomy of the bladder

Your bladder is supported by a varied system of muscles:

• The sphincter encircles the urethra, the tube that carries urine outside of your body.
• The detrusor is the muscle of the bladder wall, which allows it to expand.
• The pelvic floor muscles help support the bladder and the urethra.

To hold urine inside your bladder without leakage, you need to be able to contract your sphincter. When your sphincter and pelvic muscles are weak, it’s more difficult to contract these muscles and the result is called as stress incontinence.

Stress incontinence symptoms

The main symptom of stress incontinence is the loss of bladder control during physical activity. You may experience a few drops of urine or a large, involuntary flow. This can happen while you are:

• laughing
• sneezing
• coughing
• jumping
• exercising
• doing heavy lifting
• engaging in sexual intercourse

Sometimes even standing up from a seated or reclining position can put additional pressure on your bladder and cause a leakage. Stress incontinence is unique for every individual. You may not show symptoms every time you participate in an activity, and the same activities that cause leakage for you may not affect another person with stress incontinence.

Who suffers from stress incontinence?

Women are twice as likely as men to suffer from involuntary leakage. The most common causes of stress incontinence among women are pregnancy and childbirth, especially having multiple vaginal deliveries. During pregnancy and childbirth, the sphincter and pelvic muscles stretch out and are weakened.

Older age and conditions that cause a chronic cough can also cause stress incontinence. This condition can also be a side effect of pelvic surgery.

Some women only suffer from stress incontinence during the week before they get their period. Various studies explain that estrogen drops during this phase of the menstrual cycle, which can weaken the urethra. This is not common though.

Other risk factors for stress incontinence include:

• smoking due to chronic cough
• any other condition associated with chronic cough
• excessive caffeine and alcohol use
• obesity
• constipation
• long-term participation in high-impact activities

Treatment

Your Gynecologist may recommend a combination of treatment strategies to end or lessen the number of incontinence episodes. If an underlying cause or contributing factor, such as a urinary tract infection, is identified, you’ll also receive treatment for the condition.

Behavior therapies

Behavior therapies may help you eliminate or lessen episodes of stress incontinence. The treatments your doctor recommends may include:

• Pelvic floor muscle exercises. Called Kegel exercises, these movements strengthen your pelvic floor muscles and urinary sphincter. Your doctor or a physical therapist can help you learn how to do them correctly. Just like any other exercise routine, how well Kegel exercises work for you depends on whether you perform them regularly.

A technique called biofeedback can be used along with Kegel exercises to make them more effective. Biofeedback involves the use of pressure sensors or electrical stimulation to reinforce the proper muscle contractions.

• Fluid consumption.Your doctor might recommend the amount and timing of fluids you consume during the day and evening. However, don’t limit what you drink so much that you become dehydrated.

Your Gynecologist may also suggest that you avoid caffeinated and alcoholic beverages because it’s believed that in some people these dietary irritants affect your bladder function. But, new research suggests that coffee and caffeine may not increase stress incontinence. If you find that using fluid schedules and avoiding dietary irritants significantly improves leakage, you’ll have to decide whether these changes are worth the improvement in leakage.

• Healthy lifestyle changes.Quitting smoking, losing excess weight or treating a chronic cough will lessen your risk of stress incontinence as well as improve your symptoms.
• Bladder training.Your doctor might recommend a schedule for toileting (bladder training) if you have mixed incontinence. More frequent voiding of the bladder may reduce the number or severity of urge incontinence episodes.

Medications

There are various approved medications to specifically treat stress incontinence.The antidepressant duloxetine (Cymbalta) is used for the treatment of stress incontinence.

Devices

Certain devices designed for women may help control stress incontinence, including:

• Vaginal pessary. A specialized urinary incontinence pessary, shaped like a ring with two bumps that sit on each side of the urethra, is fitted and put into place by your doctor or nurse. It helps support your bladder base to prevent urine leakage during activity, especially if your bladder has dropped (prolapsed).

This is a good choice if you wish to avoid surgery. A pessary will require routine removal and cleaning. Pessaries are used mostly in people who also have pelvic organ prolapse.

Surgeries

Laparoscopic bladder neck repair, Kelly’s repair, sling operations,  burch colposuspensipn, TVT tape colposuspensipn are some of the surgical options.

Recently transvaginal RF LASER treatment is giving good results in stress and mixed incontinence.

Dr.Ruchi Tandon is a Gynecologist with 13 years experience in all cases of urinary leakage and urinary incontinence. She is practicing in leading hospitals in South Delhi.

A miscarriage, also called a spontaneous abortion, is the spontaneous ending of a pregnancy. About 1/3 to 1/2 of all pregnancies end in miscarriage before a woman misses a menstrual period or even knows she is pregnant. About 10 to 20% of women who know they are pregnant will miscarry , mostly in the first three months.

A miscarriage is most likely to occur within the first 3 months of pregnancy, before 20 weeks gestation. Very few of miscarriages occur after 20 weeks’ gestation. These are termed late miscarriages.

What causes miscarriage?

About half of all miscarriages that occur in the first trimester are caused by chromosomal abnormalities, which might be hereditary or spontaneous , in the father’s sperm or the mother’s egg. Chromosomes are tiny structures inside the cells of the body that carry many genes, the basic units of heredity.

Genes determine all of a person’s physical attributes, such as sex, hair and eye color and blood type. Most chromosomal problems occur by chance and are not related to the mother’s or father’s health.

Miscarriages are also caused by a variety of unknown and known factors, such as:

1. Infection
2. Exposure to environmental and workplace hazards such as high levels of radiation or toxic agents.
3. Hormonal irregularities.
4. Improper inplantation of fertilized egg in the uterine lining.
5. Maternal age.
6. Uterine abnormalities.
7. Incompetent cervix. (The cervix begins to widen and open too early, in the middle of pregnancy, without signs of pain or labor.)
8. Lifestyle factors such as smoking, drinking alcohol, or using illegal drugs.
9. Disorders of the immune system including lupus, an autoimmune disease.
10. Severe kidney disease.
11. Congenital heart disease.
12. Diabetes that is not controlled.
13. Thyroid disease.
14. Radiation
15. Certain medicines, such as the acne drug isotretinoin .
16. Severe malnutrition.
17. Infections

What are the symptoms of a miscarriage?

Symptoms of a miscarriage include:

• Bleeding that progresses from light to heavy.
•  
• Abdominal pain.
• Low back ache that may range from mild to severe.

If you are experiencing the symptoms listed above, contact your Gynecologist right away. She will tell you to come in to the office or go to the labor room.

How Is a Miscarriage Diagnosed and Treated?

Your Gynecologist will perform a pelvic exam, an ultrasound test and bloodwork to confirm a miscarriage. If the miscarriage is complete and the uterus is empty, then no further treatment is usually required. Occasionally, the uterus is not completely emptied, so a dilatation and curettage (D&C) procedure is performed. During this procedure, the cervix is dilated and any remaining fetal or placental tissue is gently removed from the uterus. As an alternative to a D&C, certain medicines can be given to cause your body to expel the contents in the uterus. This option may be more ideal in someone who wants to avoid surgery and whose condition is otherwise stable.

Blood work to determine the amount of a pregnancy hormone (hCG) is checked to monitor the progress of the miscarriage.

When the bleeding stops, usually you will be able to continue with your normal activities. If the cervix is dilated, you may be diagnosed with an incompetent cervix and a procedure to close the cervix (called cerclage) may be performed if the pregnancy is still viable. If your blood group is Rh negative, your doctor may give you a blood product called Rh immune globulin (Rhogam). This prevents you from developing antibodies that could harm your baby as well as any of your future pregnancies.

Blood tests, genetic tests, or medication may be necessary if a woman has more than two miscarriages in a row (called recurrent miscarriage). Some diagnostic procedures used to evaluate the cause of repeated miscarriage include ultrasound, hysterosalpingogram (an X-ray of the uterus and fallopian tubes), and hysteroscopy (a test in which the doctor views the inside of the uterus with a thin, telescope-like device inserted through the vagina and cervix).

Can I Get Pregnant Following a Miscarriage?

Yes. At least 85% of women who have miscarriages have subsequent normal pregnancies and births. Having a miscarriage does not necessarily mean you have a fertility problem. On the other hand, about 1%-2% of women may have repeated miscarriages (three or more). Some researchers believe this is related to an autoimmune response.

If you’ve had two miscarriages in a row, you should stop trying to conceive, use a form of birth control, and ask your Gynecologist to perform diagnostic tests to determine the cause of the miscarriages.

Dr. Ruchi Tandon, is a Gynecologist with over 13 years experience in obstetrics and Gynecology, practicing in leading hospitals in South Delhi. She is approachable, experienced and highly competent in handling all types of pregnancies.