While in clinical practice the normal duration of the menstrual flow is easy to establish, lasting about 3 to 5-6 days, unfortunately the same cannot be said regarding the average amount of the normal menstrual blood loss. This means that, in the daily gynecologic practice, it is the patient who actually tells and "establishes" if the volume of her menstrual flow has increased or is reduced, and this is done by comparing it with her usual own personal standard. Sometimes there is a rough comparison with the menstrual bleeding of relatives or friends. Thus, there is often a considerable subjectivity in this evaluation. Unfortunately, Gynecology has failed to establish a reliable parameter for evaluating the daily or total menstrual blood loss that could be easily applicable to clinical practice. Maybe an experiment carried out with women who make use of menstrual cups can give us some help ( as to menstrual cups, see the wonderful "Museum of Menstruation and Women's Health" ).

Prolonged and/or excessive menstrual bleedings comprise basically two main groups: the functional and the organic ones. The functional ( or dysfunctional ) excessive menstrual bleedings have their main cause in hormonal or congestive disorders, while the organic ones are mostly caused by fibroids ( uterine leiomyomata ), polyps and cancer. The association between some excessive and/or prolonged uterine bleedings with some pre-carcinogenic lesions and cancer obliges us to pay attention to all cases of hypermenorrhea and menorrhagia - though, fortunately, most of them are due to entirely benign causes.

Most functional ( or dysfunctional ) excessive menstrual bleedings are caused by hormonal disorders characterized by absolute or relative hyperestrogenism due to a deficiency of progesterone. Remember that, in the first phase of the normal ovulatory cycles, the estrogens produce remarkable proliferative effects in the endometrium that are, after ovulation and in the second phase, counterbalanced and opposed by the anti-proliferative and secretory actions of progesterone upon this tissue. As a result, the proliferative estrogenic endometrium is turned into the secretory progesteronic endometrium. Nevertheless, if there is a deficiency of progesterone due to luteal insufficiency or mostly persistent anovulatory cycles ( in which there is no progesterone, except in clinically non-significant minimal basal levels ), the proliferative and unopposed effect of the estrogens alone will take place along the entire cycle, being able to cause excessive thickenings of the endometrium named endometrial hyperplasias. ( For luteal insufficiency, see Note 1, below. As to the anovulatory cycles, in which there is no ovulation and no corpus luteum formation, resulting in the absence of progesterone, see my article "Anovulatory Cycles".)

The hyperplastic and excessively thickened endometrium does not desquamate ( shed its lining ) easily or even completely at the end of the cycle, resulting in prolonged and/or excessive menstrual bleedings. In a simplified and didactical way, we may say that, in these hyperplasias, there is "too much endometrium to desquamate" and, therefore, to bleed. In this way, most of the dysfunctional menstrual bleedings are due to endometrial hyperplasias resulting from a persistent estrogenic action upon the endometrium, and this happens mostly as a consequence of anovulation. And, if the anovulatory cycles last longer than the normal duration of the menstrual cycle and the estrogenic production is normal or heightened, the possibility of development of endometrial hyperplasias becomes greater, together with the occurrence of hypermenorrhea and menorrhagia.

In spite of the frequent occurrence of dysfunctional uterine bleedings throughout the entire women's fertile years, their frequency is greater immediately after menarche and mostly along the years that precede menopause. This is due to the higher incidence of anovulatory cycles ( as well as luteal insufficiency ) in puberty and pre-menopause. In puberty, anovulatory cycles and the defective luteal phase result from the normal process of maturation of the hypothalamus-pituitary-ovaries axis, whereas in pre-menopause their main cause is just the aging and progressive depletion of the ovaries.

Almost all functional prolonged and/or excessive uterine bleedings due to non-complicated endometrial hyperplasias cease with the administration of progestins ( synthetic progesterones ) alone or associated with estrogens. ( Estrogens alone must never be given because they aggravate the hyperplasias, and this must be quite clear.) The use of a progestin like norethysterone in an adequate dose for approximately 10 days usually stops the dysfunctional bleeding in a few days, promoting the secretory transformation of the hyperplastic endometrium and its normal desquamation 3 to 4 days after the end of the series. If, in some cases, the progestin alone does not succeed in stopping the bleeding, the association of the progestin with some estrogen may help. Nevertheless, as said above, estrogens alone must never, never be used.

For preventing the occurrence of further episodes of hypermenorrhea or menorrhagia, the use of almost all progestins ( or even natural micronized progesterone ) also for approximately 10 days along the second half of the cycle ( from the 16th to the 25th day, for instance ) is advisable. The use of the combined hormonal oral contraceptives is also indicated, since their balanced synthetic progestin-estrogen association taken in series of 21 days with a 7 days interval between the series prevents the development of endometrial hyperplasias. That's why the use of the combined type of "Pills" reduces the incidence of endometrial cancer, since some special kinds of endometrial hyperplasias are precursors of this neoplasia.

Conversely, prolonged and/or excessive uterine bleedings due to organic causes, like fibroids, polyps and cancer do not respond to hormones. That means that they do not cease or diminish with hormonal therapy, and this is also a very important test in clinical practice, allowing us to know with a considerable degree of certainty if an abnormal uterine bleeding is due to a functional or an organic cause. Of course, there are exceptions and "in-between" situations.

There are several kinds of hyperplasias of the endometrium, as well as several classifications for them. These endometrial alterations are studied based not only on the histological architecture of the endometrial glands but also on the features of their cells. Basically, for a didactic and practical purpose, endometrial hyperplasias can be typical or atypical. The typical endometrial hyperplasias are the most frequent ones and, fortunately, are histologically benign. They comprehend the simple and the cystic glandular endometrial hyperplasias. On the other hand, the atypical - or adenomatous - endometrial hyperplasias do have an important relationship with the genesis of endometrial cancer.

For a long time these atypical endometrial hyperplasias were classified in slight, moderate and accentuated atypical hyperplasias of the endometrium. Among them, the accentuated type basically corresponds to the adenocarcinoma in situ of the endometrium ( the first stage of endometrial cancer ). In this way, the management of typical or atypical endometrial hyperplasias differs a lot. Nevertheless, to speak of the treatment of the atypical endometrial hyperplasias is not the purpose of this article. Endometrial cancer or adenocarcinoma of the uterine corpus is more frequent in women above the age of 50, but also may occur earlier. For that reason, any uterine bleeding in post-menopausal women who are not on hormonal replacement therapy requires immediate and careful investigation.

As to the aforementioned functional congestive disorders that also may cause increased menstrual bleedings, they are related to the pelvic congestion syndrome, characterized by variable degrees of vascular stasis resulting on a persistent engorgement in the female genitals, ligaments and near organs and tissues. There are also other symptoms like pelvic and lumbo-sacral pain and discomfort, and the condition may be due to sexual and psychosomatic problems. The main sexual problem that may cause pelvic congestion seems to be persistent sexual excitement without orgasmic response.

I also must emphasize the great importance of psychosomatic factors in the origin or aggravation of almost all kinds of functional uterine bleedings, hormonal and functional disorders in Gynecology. Here, the psychosomatic influences are exerted mostly through the neuroendocrine and neurovegetative pathways, the neuroendocrine being the most important one. Regarding this subject, see "Clinical and Psychosomatic Gynecology" and "Psychosomatic and Symbolic Aspects of Menstruation".

As to the organic causes for prolonged and/or excessive menstrual bleedings, the most frequent ones are the widely known uterine leiomyomatas or fibroids. Nevertheless, not all kinds of fibroids cause abnormal uterine bleedings. In order to cause hypermenorrhea and/or menorrhagia, fibroids must grow towards the uterine cavity, protruding inside it, distorting its shape and/or increasing its size. This causes compressive and congestive alterations in the endometrium, leading to the excessive bleedings. Basically, there are three kinds of fibroids, according to their position in the uterus: the submucous, intramural and subserous ones.

Submucous fibroids are the ones that more easily cause uterine abnormal bleedings, because they grow close and towards the uterine cavity, protruding inside it and exerting a direct pressure upon the endometrium. Some of them are even pedunculated ( growing on stalks ). Intramural fibroids grow in the middle of the uterine wall and, therefore, need to reach a considerable size in order to protrude inside the uterine cavity and cause the bleedings. Nevertheless, the growth of multiple intramural fibroids may cause a diffuse uterine enlargement accompanied by several distortions and alterations in the shape of the uterine cavity, also resulting in hypermenorrhea and/or menorrhagia. Subserous fibroids are those that grow close and towards the uterine outer surface, distant from the uterine cavity. For that reason, they do not cause menstrual alterations.

As in all cases of hypermenorrhea and/or menorrhagia due to organic pathologies, abnormal uterine bleedings caused by fibroids do not respond to the use of progestins or progestin-estrogen associations. Nevertheless, sometimes there are exceptions: cases in which the presence of the fibroids coexist with endometrial hyperplasias due to hyperestrogenism. Cases like these are relatively frequent and, in this way, the intensity of the abnormal bleedings may, at least, be reduced with the use of progestins. This means that, sometimes, cases of excessive menstrual bleeding whose main cause is attributed to existing fibroids actually may have their main origin in hormonal disorders and resulting simple endometrial hyperplasias, which can be treated with progestins.

The treatment of uterine fibroids that undoubtedly are causing abnormal menstrual bleedings ( or even other problems, depending on their position and size ) unfortunately remains mostly surgical ( see Note 2, below. ) Even so, with the present-day great development of endoscopic surgery ( especially the hysteroscopic ones ), the operation treatment of fibroids became much more conservative and less invasive and aggressive than in the past. Submucous fibroids, for instance, presently are easily removed with a hysteroscopic surgery, performed by introducing a highly sophisticated endoscopic-surgical-optical device inside the uterine cavity through the vagina. Endometrial polyps, another organic cause of abnormal bleedings, are also easily removed by the same procedure ( see Note 3, below ).

Fibroids ( or uterine leiomyomata ) are very frequent and fortunately benign tumors of the myometrium ( the uterine muscular layer ). They are formed by a mixture of smooth muscle fibers and fibrous connective tissue and grow into nodules. Their possibility of malignant transformation is extremely low and, for that reason, usually is not considered in clinical practice.

Before finishing I would like to remark that this is only an introductory and very brief article about the extremely complex and intricate subject of the prolonged and/or excessive menstrual bleedings. Because of this and considering not only the limitations of an article written for the web but also the unimaginable extent and complexity of the subject, this article cannot be regarded as a truly specialized approach to menstrual disorders like hypermenorrhea, menorrhagia and other abnormal kinds of uterine bleedings. Thus, this article is inevitably too, too far from being complete, and I think ( and hope ) that this is quite obvious to the readers. I also would like to remark that to speak of the abnormal uterine bleedings due to endometrial cancer was not the purpose of this article.

Note 1: Luteal insufficiency is a condition in which the production of progesterone by the corpus luteum is deficient. A deficient corpus luteum, though producing low progesterone levels, may last the usual 12 to 14 days or less ( 7 to 10 days ). In the last case, there is a luteal insufficiency due to a short luteal phase.

Note 2: Sadly, the recent attempts at developing a medicinal treatment for uterine fibroids have proved to be disappointing - at least on a long-term basis and mostly considering its side-effects. As everybody knows, the growth of fibroids depends on the estrogens, since these hormones are the main responsible factors for the appearance and development of these tumors. That's why the size of fibroids is naturally greatly reduced ( and some of them even disappear ) after menopause in women who are not on hormonal replacement therapy. Based on this, a treatment with Gn-RH analogues was developed in order to promote an intense blockage of the ovarian function resulting in very low estrogen levels ( like those existing in natural menopause ) and, consequently, in a considerable reduction in the size of fibroids during the treatment. Nevertheless ( and obviously ), the use of this medicine also produces great genital atrophy and almost all signs and symptoms of menopause ( including even some degree of osteoporosis ). For that reason, Gn-RH analogues cannot be used for periods of time longer than six months. Despite the great reduction in the fibroids' size obtained during the treatment, a few months after its interruption and due to the subsequent return of the ovarian function to normal, the fibroids grow up again. Because of this, this treatment is only used in a few clinical situations.

Note 3: As to hysteroscopy, it is also an excellent way of establishing the exact cause of abnormal uterine bleedings, since it allows a direct observation of the entire uterine cavity at high magnification and, if necessary, to perform a biopsy with precision. Nevertheless, as it is an invasive procedure, in my opinion, as a clinical gynecologist, we only must recommend a hysteroscopy when it is absolutely necessary.

P.S.: "Embolization" is a new procedure that is being developed as an alternative to the surgical treatment of fibroids, though some of its aspects remain somewhat controversial. Basically it consists on the catheterization of the uterine arteries under radiologic control and the introduction of a substance that temporarily blocks part of the uterine blood supply, causing a partial necrosis of the fibroids. The problem is that, together with the fibroids, there is also a necrosis of part of the normal uterine tissues, implying some risks and possible considerable side-effects. Nevertheless, a further development of the technique certainly will bring us new perspectives in the conservative treatment of uterine leyomiomata.

Nelson Soucasaux is a gynecologist dedicated to Clinical, Preventive and Psychosomatic Gynecology. Graduated in 1974 by Faculdade de Medicina da Universidade Federal do Rio de Janeiro, he is the author of several articles published in medical journals and of the books "Novas Perspectivas em Ginecologia" ("New Perspectives in Gynecology") and "Os Órgãos Sexuais Femininos: Forma, Função, Símbolo e Arquétipo" ("The Female Sexual Organs: Shape, Function, Symbol and Archetype"), published by Imago Editora, Rio de Janeiro, 1990, 1993.

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Email: nelsons@nelsonginecologia.med.br