Menorrhagia as a result of Hormonal Imbalances in Women
December 28, 2021
Introduction
Key words: Abnormal Uterine Bleeding, Hormone imbalance, Anovulatory cycle, Endocrine system, Hypothalamic-pituitary-ovarian axis, Progesterone, Luteinizing hormone secretion, Menstrual Disorder
Menorrhagia, a type of abnormal uterine bleeding (AUB), affects one-third of women of child-bearing age (Jones & Sung 2021). Menorrhagia is defined as heavy or abnormal menstrual bleeding involving a loss of more than 80 mL of blood during menses, or having menses longer than seven days. Along with heavy bleeding, AUB includes abnormalities in the cycle, of either the volume, frequency, or duration of menstruation. The most common cause of abnormal uterine bleeding is ovulatory dysfunction (AUB-O), typically seen in women under 45 and adolescents (Pinkerton 2020). This supports the idea that menorrhagia is caused and affected by the hormone changes and imbalances that accompany the monthly menstrual cycle. This is further supported by (Ray & Ray, 2016) as they have stated that “heavy menstrual bleeding without an organic lesion is mainly due to an imbalance of the various hormones which have a regulatory effect on the menstrual cycle”. However, most women who have any type of AUB are conditioned by mainstream medicine and societal beliefs that to suffer each month is their fate.
The most common treatments given to women with menstrual disorders is a version of hormonal therapy. There are several issues surrounding this type of treatment; potential to interfere with women’s abilities to start families, disrupt their hormones or their bodies ability to naturally cycle as intended by their biological nature. When this process is suppressed for any length of time, any hormone imbalances or menstrual disorders are often worsened, and many symptoms present before hormonal therapy will return exacerbated. Avoiding the use of birth control for AUB by discovering the root cause of hormone imbalances is essential. Identifying nutrition’s role in correcting these hormones, and subsequently menstrual irregularities, is crucial in understanding both the cause and natural treatment of Menorrhagia. This will help prevent the unnecessary over-use of birth control and positively affect women’s health.
Causes of Menorrhagia
Abnormal uterine bleeding due to ovulatory dysfunction (AUB-O) is a diagnosis of exclusion. Whether one is suffering from an irregular, prolonged, or heavy menstrual cycle, there are many causes of abnormal uterine bleeding. These causes are classified as either structural or non-structural. PALM-COEIN, an acronym coined by The International Federation of Gynaecology and Obstetrics, is used to aid in classification and subsequently understand the cause and treatment of AUB. Reference table below.
Structural
P - Polyps
A - Adenomyosis (endometriosis within the uterus myometrium)
L - Leiomyoma (fancy word for fibroids)
M - Malignancy (precancerous hyperplasia within the endometrium)
Non-structural
C - Coagulopathy
O - Ovulation dysfunction
E - Endometrial (dysfunctional uterine bleeding)
I - Iatrogenic (contraceptives cause this)
N - Not yet classified
Other possible causes of AUB not included in PALM-COEIN can be attributed to thyroid disorders or medications such as antipsychotics or antidepressants (Jones & Sung, 2021).
Once all other potential causes are ruled out, ovulatory dysfunction can be diagnosed. Despite the many different possible causes; “Eighty percent of women treated for heavy menstrual bleeding have no anatomical pathology and over one third of the women undergoing hysterectomies for heavy menstrual bleeding have anatomically normal uteri removed” (Clarke 1995; Gath 1982 as stated in Ray & Ray 2016). This fact rules out all structural (PALM) causes of AUB and supports Pinkerton’s (2020) statement that the most common cause of abnormal uterine bleeding is ovulatory dysfunction (AUB-O). Thus, most women with menorrhagia have AUB-O if their heavy bleeding cannot be attributed to PALM-COEIN.
Ovulatory dysfunction (AUB-O) can be divided into two types; anovulatory and ovulatory. The first affects 90% of cases while the latter affects the remaining 10% (Pinkerton, 2020). An anovulatory cycle means ovulation is not taking place; progesterone is not secreted which causes the endometrium of the uterus to proliferate until it sloughs off incompletely, irregularly or profusely for an extended period of time. There are many possibilities as to why progesterone is not secreted which will be explained thoroughly in the following sections. Another reason is that “Physiologic anovulation is common at the beginning of reproductive life when the hypothalamic-pituitary-ovarian axis is not yet mature” (Jones & Sung 2021). To restate, 90% of women with AUB-O do not ovulate, causing excessive or abnormal bleeding.
Signs and Symptoms of Menorrhagia
There are a wide variety of signs and symptoms that lead to the diagnosis of Menorrhagia. Signs of Menorrhagia include heavy bleeding, a menses over seven days or loss of more than 80 mL of blood, passing large blood clots, changing a menstrual pad or tampon every hour for several hours, or iron deficiency anemia. Common symptoms are premenstrual symptoms; breast tenderness, mid cycle cramping pain (mittelschmerz), abdominal pain, fatigue, dizziness.
Treatment Options
After discussing ways to identify the presence of Menorrhagia, women must be offered effective ways to restore the hormonal balance in their bodies. Women who complain of AUB to their doctor are often offered a limited number of conventional solutions to solve their condition, including drugs or hormones which hide and suppress their symptoms, thus ignoring the root cause of the problem. For example, the most common treatment, oral contraceptives, suppress pituitary gonadotropin release which starts the domino reaction of preventing ovulation; thus causing 50-60% less blood flow during menses (Livdans-Forret, Harvey, & Larkin-Thier, 2007). Other hormone therapies options are oral progesterone, and hormonal IUDs. As stated by Hickey, Higham, & Fraser, (2012) “Progestogens, and oestrogens and progestogens in combination, are widely used in the management of irregular menstrual bleeding”.
Non-hormonal treatments are said to have fewer risks and adverse effects, and are used for women who wish to fall pregnant or avoid hormone therapy. These include Nonsteroidal anti-inflammatory drugs (NSAIDs), which lower the level of prostaglandin levels and cause menstrual flow to be reduced by 22-50% (Livdans-Forret et al., 2007). As well as NSAIDS, there is tranexamic acid that reduces blood loss by 40-60% (Pinkerton, 2020). Another medicine used that reduces blood loss is gonadotropin-releasing hormone agonist. It does so by preventing the release of Follicle Stimulating Hormone and Luteinizing Hormone from the pituitary gland (Livdans-Forret et al., 2007).
Surgical procedures and treatments considered for Menorrhagia include; endometrial ablation (burning endometrium to minimize amount shed), hysterectomy, or laparoscopic ovarian drilling are the last resort of AUB treatments. This is due to fertility removal/risks involved.
The issue with these treatment options is that very few of them truly solve the problem. Doctors are involved with big pharma companies in which they have a fluid system benefiting both parties, excluding the suffering patient. Most of these treatments work by targeting, suppressing or manipulating hormones and the menstrual cycle. These solutions “work” for many women, that is until they no longer want contraception, to constantly be taking drugs, or are fed up with the nasty side effects. These women may feel empowered to reap the benefits of menstruating and cycling naturally and strive to truly heal their AUB with the power of nutrition, holistic therapies, and the body.
Methods of Alternative Treatments
Women provided help from mainstream medicine are very rarely offered alternative treatments. Balancing hormones through natural approaches is not widely accepted by the mainstream medical community yet, despite the vast research available on the subject. The endocrine system dictates the maintenance of homeostasis in the body through a variety of endocrine glands and feedback loops. Menorrhagia is a loss of homeostasis in the body, and of course, the endocrine system wants to return to homeostasis and can, with support. Dietary support is only one way to help rebalance hormones, but an improper diet is one of the major endocrine disruptors. Other endocrine disruptors can include lack of sleep, stress, certain chemicals and toxic products, medications, pesticides, or stagnant digestion. Eating patterns and habits are just as important as the nutrients themselves. Poor eating habits, such as skipping meals, eating fast or on the go can weaken digestion and raise cortisol. Elevated secretion of cortisol will create a negative feedback loop to inhibit both the hypothalamus and the pituitary gland, decreasing the preovulatory Luteinizing Hormone peak. “Various types of stress disrupt the follicular phase of the ovarian cycle and delay or block the preovulatory luteinizing hormone (LH) surge” (Wagenmaker et al., 2008). These stressors can be from exercise, food restriction or environmental toxins.
There are three very important endocrine glands involved in the ovulatory cycle and thus in AUB-O. These are the hypothalamus, pituitary and ovary. This is supported by Nedresky & Singh (2021); “Ovulation is made possible due to the combined actions of the hypothalamus, pituitary, and ovary.” As well there are three chemical messengers (hormones) released from these endocrine glands that play a large role in triggering ovulation. These are Gonadotropin‐releasing hormone (GnRH), Follicle-stimulating hormone (FSH) and Luteinizing hormone (LH). The hypothalamus produces GnRH which stimulates the release of FSH and LH from the pituitary gland. FSH and LH regulate ovarian activity. The release of GnRH, FSH, and LH can be suppressed by estrogens, as in the case of hormonal birth control use. Luteinizing hormone is especially important for triggering ovulation and stimulating secretion of progesterone. “Additionally, LH helps to regulate the length and order of the menstrual cycle in females by playing roles in both ovulation and implantation of an egg in the uterus” (Nedresky & Singh 2021). In sum; an anovulatory cycle can be caused by excess estrogens, dysfunctional hypothalamus or pituitary gland, hyposecretion of GnRH, FSH or LH and consequently less secretion of progesterone. This underexcretion of progesterone, as stated previously, causes excessive and abnormal bleeding.
Dietary Therapies
There are many dietary practices women can implement in their daily life to assist the balancing of these integral hormones that control the menstrual cycle. Estrogen is metabolised in the liver, lignans bind to estrogen and aid to flush estrogen out through the intestines. The balance of progesterone and estrogen go hand in hand as excessive estrogen suppresses progesterone, thus elimination of estrogen will help encourage normal progesterone levels. “Fiber intake and urinary excretion of lignans and equol correlated negatively with plasma percentage free estradiol. Enterolactone excretion correlated negatively with plasma free testosterone. It is concluded that dietary macro- and micronutrients seem to play an important role in estrogen metabolism.” (Adlercreutz et al., 2003). A deficiency of B vitamins can affect the liver and its ability to flush estrogens, suggesting a deficiency of these vitamins may play a role in estrogen metabolism. “Two foods that have been repeatedly mentioned in their ability to regulate the menstrual cycle are flax seeds and soy protein” (Hudson 2007) as cited in (Livdans-Forret et al., 2007). A study conducted in which women were given vitamin A to treat Menorrhagia; “In the group who received 60,000IU of vitamin A for 35 days, menstruation returned to normal in 23 patients (57.5%) and was reduced in 14 (35%)” (Livdans-Forret et al., 2007). Essential minerals and antioxidants both play a role in progesterone levels and anovulation risk. Minerals shown to be supportive in ovulation are zinc, copper, magnesium, calcium, manganese, and iron. “There is ample evidence showing that minerals are important for reproductive function in women. Minerals may be associated with ovulation” (Kim et al., 2018). As previously stated, food restriction or undernutrition can be detrimental to the menstrual cycle. A study done by Ponzo et al., (1999) suggests a lack of protein in the diet of rats reduces secretion of LH in female rats. A similar study done on lambs shows a restriction of dietary protein delays ovulation and reduces LH concentrations in the plasma. (Polkowska 1996). Furthermore, this theory is further supported by a study done in 2011 on goats showing the role of nutrition on regulation of LH secretion (Zaraaga et al., 2011).
Alternative Therapies
Therapeutic Herbs have shown to be supportive in the treatment of Menorrhagia. Chaste Tree-Berry (Vitex Agnus Castus) is a well-known herb supplement for the treatment of menstrual disorders. It is one of the most widely studied herbs with substantial evidence in its effect in regulating the menstrual cycle. “It acts upon the hypothalamus and pituitary gland with its progesterone-like effect, increasing luteinizing hormone and inhibiting the release of follicular stimulation hormone resulting in a shift of the ratio of estrogen and progesterone” (Livdans-Forret et al., 2007). Red Raspberry Leaf (Rubus Idaeus) is another herb used for menstrual as well fertility issues and is shown as a uterine tonic (Griffith, 2000). The leaves contain citric acid, carotenoids, vitamin A, vitamin B and tannins, all of which are individually shown to support ovulation and the hormones involved. There is less available research on the herb itself in supporting AUB-O.
As well as herbal medicines, there are a variety of body holistic therapies that have been studied to treat Menorrhagia. As well as being influenced by hormones, the uterus and ovaries are controlled by sympathetic and parasympathetic nerve fibres. Sympathetic nerve fibers attach to the ovary from the 10th and 11th thoracic spinal segment. “Parasympathetic activity may produce uterine inhibition and vasodilatation” (Livdans-Forret et al., 2007). This suggests that misalignment of the spinal cord, especially in the thoracic vertebrae, could affect the function of the ovaries and uterus. Furthermore, issues in the autonomic nervous system could cause overstimulation of the nerve fibres that run to the ovaries and uterus. The hypothalamus acts as a coordinator for the autonomic nervous system, and as previously stated, the hypothalamus is also integral for the release of the hormones GnRH and subsequently LH and FSH.
Acupuncture is another type of body therapy that has been used for many illnesses and ailments in traditional Chinese Medicine for over 3000 years (Hao & Mittelman, 2014). Recently, more women have been seeking out alternative body treatments to help manage Menorrhagia, including acupuncture. In acupuncture, professionals practice using trigger points; energy pathways (meridians), or specific points which stimulate our central nervous system. “This, in turn, releases chemicals into the muscles, spinal cord, and brain. These biochemical changes may stimulate the body's natural healing abilities and promote physical and emotional well-being.” Johns Hopkins Medicine (2021). Research from China also suggests that acupuncture is effective in the treatment of menorrhagia. In a study of acupuncture in 30 patients with uterine bleeding disorders, 90% saw improvement. In a second study by Liu & Zhang (1998), 83% of 50 cases were cured, 10% showed effective results and 4% showed effective results. In a survey of patients visiting acupuncturists, 92% of those visiting for gynecological conditions had reported that their symptoms had either improved or disappeared (Walsh & Polus) as cited in (Livdans-Forret et al., 2007).
Long Term Prognosis
Untreated menorrhagia caused by AUB-O is not usually life threatening, although too much blood loss can become an emergency situation. Menorrhagia from any other PALM-COEIN cause could be life threatening (uterine or cervical cancer). Menorrhagia unmanaged can cause iron deficiency anemia, producing symptoms such as fatigue, dizziness, weakness, shortness of breath etc. Left unmanaged, Menorrhagia can result in a necessary hysterectomy.
Summary
Women are fortunate to live in a time and place where they have options and access around such life changing medicine, but it is imperative to educate women fully on alternative treatments and offer support through these holistic therapies. Menorrhagia affects over 10 million women per year according to the CDC (2017).
The too common stories of the 14-year-old girl too tired and dizzy to stand up, the 16-year-old skipping school, the 18-year-old with random weight gain, the 22-year-old burdened by her own her emotions, the 26-year-old with adult acne, the 30-year-old unable to start a family, the 42-year-old who can’t keep weight off, the 52-year-old women undergoing a hysterectomy… These tired stories can be prevented. Doctors need to openly invite women to explore and consider both options of conventional and alternative therapies, with all side effects stated clearly. Women need education and support from when they are girls. Having knowledge of their menstrual cycle, hormones involved and the signs and symptoms of menstrual disorders can be the difference between women silently struggling and living a vibrant, confident, healthy life.
Women’s menstrual issues need to be considered from a holistic standpoint to help women take control of their health and support their reproductive system. A system mostly responsible for life is too often ignored, spoken about with shame, and not supported. To change this starts at the beginning, and from the inside. Learning one’s own source of hormone imbalance and supporting her hormones through each phase of her cycle, with the combination of nutrition and holistic therapies (herbs, sleep, toxin free environments, somatic care, mental support, acupuncture) is essential to fully support the reproductive and endocrine systems return to homeostasis, curing menorrhagia.
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