Treatment for Excessive Menstrual Bleeding in Rural Areas: A Look at the Available Options

When do you consider periods as excessive?

Wikipedia defines menorrhagia as “heavy and prolonged menstrual periods at irregular intervals” (1). Since there is variation in the amount and duration of periods from person to person, the excess also varies from person to person. However, a blood loss of greater than 80 ml and duration of greater than 7 days is considered abnormal (1). Since the women in rural areas do not use standard pads or tampons, it is difficult to assess blood loss. Hence, we consider it as excessive if it interferes with usual activities of the lady and lasts for a while, and it is recognized by the lady as more than usual. If large clots are present consistently, or if normal daily activities cause breathlessness, it can also mean that there is excessive menstrual bleeding.

What causes the excessive bleeding?

The normal bleeding occurs when the inner lining of the uterus, called the endometrium, peels off when there is no pregnancy. The thickness of the endometrium and the duration are the result of a delicate balance of hormones in the body. If there is any problem with the hormones, it can result in thick endometrium and excess bleeding. The ovary not releasing the egg is another cause of such bleeding, due to excess hormones.

Abnormal, non-cancerous swellings in the uterus, like fibroids and polyps, can cause excessive bleeding depending on the location (2). Sometimes, presence of muscle tissue in the endometrium (called adenomyosis) can cause excessive bleeding.

Infections in the uterus or foreign bodies in the uterus can cause increased bleeding, as they cause increased blood supply and inflammatory reactions. Uterine cancers cause abnormal bleeding which is often continuous, rather than only during periods.

Complications of pregnancy like abortions, ectopic pregnancy, etc., can cause short term excessive bleeding.

Bleeding disorders and some medications are some of the rare causes of excessive bleeding. Pain often indicates infection or inflammation.

What investigations are necessary?

The ultrasound scan is an important investigation, as it can give a lot of useful information, like the presence of fibroids, the endometrial thickness, presence of polyps, presence of pelvic inflammation, etc. A full bladder is necessary during the scan, to make sonography easy. Anemia is a complication of excess bleeding, and blood tests would support the clinical evidence. PAP smears would help in ruling out cancer. Hysteroscopy is a test where a scope is passed inside the uterus to visualize it, and if carried out under anesthesia, the treatment could be offered at the same time.

What are the treatment options that are available in rural areas?

In rural areas, the following options could be available:

  1. Medical treatment: The simplest way of managing hormonal imbalance would be to give a course of artificial hormones in a balanced way, in the form of oral contraceptive pills. Sometimes (often) this works in rural areas, but unfortunately we do not have records to substantiate this statement. Non-steroidal anti-inflammatory drugs (NSAIDs) like Brufen, diclofenac sodium, etc., can help, especially when the excess bleeding is associated with pain. Tranexamic acid is a medicine that decreases blood loss and could be tried. However anything beyond these simple measures would require a specialist to treat. Iron and folic acid supplements are of course necessary.
  2. Minimally invasive treatment: A low-cost, safe, minimally invasive treatment that we found very useful for rural areas is the endometrial resection/vaporization (3). This is possible with the urology equipment (4) for prostate surgery. It is possible as a day care surgery and has the additional advantage of having some spotting during periods, if a small portion of the endometrium is left behind, so that the women in some conservative tribal areas do not feel outcast. It is important to have some tissue for biopsy. The same method could be used for treating fibroids inside the uterus (2). It is important to note that endometrial ablation is used for those who have completed their family.
  3. Surgical treatment: Removal of the uterus, of course, solves the problem. The details of the methods available are found in reference no. 2. Single incision gasless laparoscopic surgical removal of the uterus is a safe method, especially with the use of the new vessel sealing technology. Earlier, we did vaginal hysterectomies for non-prolapsed uterus (removing the uterus through the vaginal route). This was technically more difficult, and rarely, we had to open the abdomen to control bleeding, by which time the patient can lose a lot of blood.

endoscopic removal of small fibroids

Figure 1: Small fibroid being removed during single incision gasless laparoscopic surgery

small fibroid being removed 1

Figure 2: Endoscopic removal of small fibroids in the uterus

At SEESHA Medical Services

A variety of treatment options are available at the SEESHA Karunya community hospital at Karunya Nagar, Coimbatore and at the SEESHA surgical camps at Bethesda Hospital Aizawl, Sielmat Christian Hospital at Churachandpur at Manipur, Family Health Hospital at Dimapur and the other places.

Endoscopic resection or vaporization of sub-mucosal fibroids has been carried out, and several women have conceived after this procedure, which is carried out through the vagina and cervix. Large fibroids have been removed both laparoscopically and by open surgeries.

The new procedure that is available now is the use of single incision gasless laparoscopic surgery that is used for removing the uterus and fibroids in the uterus.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

References (click to show/hide)

  1. Available from: https://en.wikipedia.org/wiki/Menorrhagia
  2. Available from: http://mdcurrent.in/patients/uterine-fibroids-symptoms-causes-and-treatment/
  3. J. Gnanaraj, Jessie Lionel. Endometrial resection/vaporization: a patient friendly first option treatment for menorrhagia in rural areas. Tropical Doctor 2008: 38: 103-104, April 2008.
  4. Available from: http://mdcurrent.in/patients/prostate-surgeries-in-rural-areas/

Feature Image: Agra, Jan Satyagraha. Source: http://www.flickr.com/photos/91487976@N05/8309268493/. Author: Yann Forget. 11 October 2012. Access the original Image information here: https://commons.wikimedia.org/wiki/File:India_woman,_Jan_Satyagraha,_Agra.jpg

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