Menstrual Blood Loss, Excessive (Menorrhagia)
• Blood loss greater than 80 ml occurring during regular menstrual cycles (cycles are usually of normal length)
Excessive menstrual bleeding, or menorrhagia, is a common female complaint that may be entirely prevented in many cases by taking proper nutritional measures. As with any disease, proper determination of the cause is essential for effective treatment. Physicians often believe they can assess menstrual blood loss by asking the patient to estimate the number of pads or tampons used during each period and the duration of the period. However, studies have demonstrated that there is no correlation between measured blood loss and these assessments.1,2 A woman’s assessment of her blood loss is extremely subjective, as demonstrated by one study finding that 40% of women with a menstrual blood loss exceeding 80 ml considered their periods only moderately heavy or scanty, whereas 14% of those with a measured loss of less than 20 ml judged their periods to be heavy.2
So how is excessive menstrual blood loss determined? Excessive blood loss should be a concern if a woman is bleeding longer than 7 straight days or more frequently than every 21 days, and is changing a pad or tampon every hour for more than half a day. Women who are changing a pad and/or tampon every half hour or at even shorter intervals often require urgent, perhaps emergency, attention. Symptoms such as lightheadedness, dizziness, and fainting are cause for immediate concern. Any amount of bleeding in a postmenopausal woman not taking hormone replacement therapy is considered abnormal.
Causes
The cause of functional menorrhagia (i.e., menorrhagia not caused by the presence of uterine fibroids or endometriosis) involves abnormalities in the biochemical processes of the endometrium (the lining of the uterus). Factors that may contribute to menorrhagia are iron deficiency, hypothyroidism, vitamin A deficiency, intrauterine devices (IUDs), and various local factors (e.g., endometrial polyps, thickening of the uterine lining, and infections).
Another cause of functional menorrhagia is abnormalities in arachidonic acid metabolism.3,4 This fatty acid is converted to hormone-like compounds known as prostaglandins. The endometrium of women who have menorrhagia concentrates arachidonic acid to a much greater extent than normal, resulting in increased production of series 2 prostaglandins, which are thought to be the major factor both in the excessive bleeding and in the accompanying menstrual cramps. Arachidonic acid is found only in animal foods such as meats and dairy products.
As noted above, a common cause of functional menorrhagia is hypothyroidism. Even minimal thyroid dysfunction may be responsible for menorrhagia and other menstrual disturbances.5 These patients often show dramatic response to thyroid hormone replacement. For more information, see the chapter “Hypothyroidism.”
Therapeutic Considerations
The first issue to address is iron deficiency, as a menstrual blood loss exceeding 60 ml per period is associated with negative iron balance in most women.6 A negative iron balance means that more iron is being lost than taken in. Although menstrual blood loss is well recognized as a major cause of iron deficiency anemia in fertile women, it is not as well known that chronic iron deficiency can be a cause of menorrhagia. This assertion is based on several observations:7
• Response to iron supplementation alone in 74 of 83 patients (in whom organic disease had been excluded)
• A significant double-blind placebo-controlled study displaying improvement in 75% of those given iron supplementation, compared with 32.5% of those given the placebo
• High rate of organic disease (fibroids, polyps, adenomyosis, etc.) in the patients with no response to iron supplementation
• Associated rise in serum iron levels in 44 of 57 patients
• Decreased response to iron therapy when initial serum iron levels were high
• Correlation of menorrhagia with depleted tissue iron stores (bone marrow) irrespective of serum iron level
In any woman suspected of having menorrhagia, it is important to rule out low iron stores by getting a blood test for serum ferritin (the first variable to indicate decreased iron levels). In one study, women who were menorrhagic had significantly lower serum ferritin levels than controls, but other iron indicators such as hemoglobin concentration, mean corpuscular volume, and mean corpuscular hemoglobin were not significantly different between the two groups.8 Yet the investigators in this study erroneously stated that such women do not require prophylactic iron supplementation, since no hematological abnormalities appeared despite significantly reduced iron stores. In fact, a decreased serum ferritin level is a good indication of the need for iron supplementation.9
Vitamin C and Bioflavonoids
Capillary fragility is believed to play a role in some cases of menorrhagia. In a study from 1960, supplementation with vitamin C (200 mg three times per day) and bioflavonoids was shown to reduce menorrhagia in 14 out of 16 patients.10 As vitamin C is known to significantly increase iron absorption, its therapeutic effect could be also due to enhanced iron absorption.
Vitamin K and Chlorophyll
Although bleeding time and clotting factors in women with menorrhagia are typically normal, vitamin K (usually in the form of crude chlorophyll preparations) has a long history of use and some clinical research support.11,12
As menorrhagia is associated with increased arachidonic acid availability in the uterus,3,4 it makes sense to decrease the intake of animal products and increase the intake of omega-3 fatty acids and other beneficial oils. Consuming higher amounts of fish, nuts, and seeds and supplementing with fish oils may yield beneficial effects by reducing tissue levels of arachidonic acid.
Vitamin B Complex
There may be a correlation between a nutritional deficiency of B vitamins and menorrhagia. It has been shown that in vitamin B complex deficiency, the liver loses its ability to inactivate estrogen. Some cases of menorrhagia are due to the effect of excessive estrogen on the endometrium. Therefore, supplementing with a complex of B vitamins may normalize estrogen metabolism. A study conducted in the 1940s showed that a B-complex preparation (thiamine 3 to 9 mg, riboflavin 4.5 to 9 mg, and niacin up to 60 mg) was effective in improving menorrhagia.13
Chasteberry
Chasteberry (Vitex agnus-castus) is probably the best-known botanical medicine for treatment of hormonal imbalances and abnormal bleeding in women. Since at least the time of the ancient Greeks, it has been used for the full scope of menstrual disorders, including heavy menses. Clinical studies have shown chasteberry extracts to be helpful in many types of menstrual abnormalities including menorrhagia. In a study observing 126 women with menstrual disorders who were given 15 drops of liquid extract, the duration between periods lengthened from an average of 20.1 days to 26.3 days in the 33 women with polymenorrhea, and the number of heavy bleeding days was shortened in the 58 patients with menorrhagia.14 While chasteberry extract is the most important botanical medicine for normalizing menstrual flow, it may take three or four months to show effects.
QUICK REVIEW
• Nutritional factors are often responsible for excessive menstrual blood loss.
• Iron therapy is a key consideration in treating menorrhagia.
• A decreased serum ferritin level is a good indication of the need for iron supplementation.
• Even mild hypothyroidism can lead to excessive menstrual blood loss.
• Consuming higher amounts of fish, nuts, and seeds and supplementing with fish oils may yield beneficial effects.
• Clinical studies have shown chasteberry extracts to be helpful in many types of menstrual abnormalities including menorrhagia.
TREATMENT SUMMARY
The first step in treating menorrhagia is to attempt to identify the cause. This step will usually require the help of a physician.
Follow the general recommendations given in the chapter “A Health-Promoting Diet.” The diet should be relatively low in meat and dairy products, to reduce the intake of arachidonic acid. It should be higher in the beneficial oils from fish, nuts, and seeds. Green leafy vegetables, green tea, and other sources of vitamin K should be consumed freely.
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin C: 500 to 1,000 mg three times per day
Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)
• Fish oils: 1,000 mg EPA + DHA per day
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Some other flavonoid-rich extract with a similar flavonoid content, super greens formula, or another plant-based antioxidant that can provide an oxygen radical absorption capacity (ORAC) of 3,000 to 6,000 units or more per day
• One of the following:
Chlorophyll: 25 mg per day (use a crude form)
1 mg vitamin K1
If low serum ferritin is confirmed:
• Iron (bound to either pyrophosphate, succinate, glycinate, or fumarate): 30 mg twice per day between meals (if this recommendation results in abdominal discomfort, take 30 mg with meals three times per day)
• Chasteberry extract:
Tablets or capsules (often standardized to 0.5% agnuside): 175 to 225 mg per day
Liquid extract: 2 to 4 ml (1/2 to 1 tsp) per day