Women’s Health

Millions of women become pregnant every year and a significant proportion of these pregnancies are complicated by one or more of the medical disorders that can occur during pregnancy. Some of the medical disorders during pregnancy are common and some are less common and some of the medical disorders during pregnancy are rare. The pattern of medical disorders during is also changing. Medical science is advancing rapidly and many medical disorders which were considered contraindications of pregnancy few decades ago are no more considered contraindication of pregnancy. Due to advancement of obstetrics, neonatology, obstetric anesthesiology, and medicine, the expectation of happy outcome of pregnancy for the mother as well as the fetus has also increased to a great extent.

Marked physiological changes occur during pregnancy (e.g. marked increase in cardiac output and workload of heart, which is as much as 40% increase) and the mother’s body need to adapt to these physiological changes appropriately to have a good outcome of pregnancy. Medical disorders which interfere with physiological adaptations of pregnancy can increase the risk of a poor outcome of pregnancy and pregnancy may sometimes aggravate the preexisting medical disorder in a woman.

The medical disorders which can occur during pregnancy are preeclampsia (development of hypertension and presence of protein in urine after 20 weeks of pregnancy or gestation) which occurs in approximately 5-7% of all pregnancies, eclampsia, gestational hypertension, aggravation of existing essential hypertension, cardiovascular disorders (like mitral stenosis, mitral and aortic regurgitation etc.), renal disorders, pulmonary hypertension, pulmonary embolism, deep vein thrombosis, hormonal disorders (like diabetes, gestational diabetes, hypothyroidism or hyperthyroidism), blood disorders, neurological disorders, gastrointestinal disorders and liver diseases. The pregnant women are also prone to develop certain bacterial (urinary tract infection, which is very common medical problem during pregnancy) and viral infections (cytomegalovirus infection, rubella, herpes, HIV infection etc.).

Conservative General Measures:

If the bleeding due to menorrhagia is not heavy and consequent anemia is not serious or hemoglobin is normal, the patient should be observed for few months, as in many cases there is spontaneous cure (recovery from menorrhagia) and it should be awaited. If the patient’s menorrhagia is severe there is always some degree of anemia. In this juncture the complete hemogram test should be done instead of doing only hemoglobin estimation. As a conservative measure oral iron preparation should be given to the patient and response to the oral iron checked by serial blood count and hemoglobin estimation (generally at least twice a month, if possible every week). If patient is not responding to iron satisfactorily due to any cause (may be due to iron intolerance, failure to utilize the oral iron etc.), she should be given parenteral iron preparation till anemia is fully corrected and body iron stores become normal. The patient should be reassured and bed rest and sedatives given, which plays important role in conservative management of menorrhagia. If anemia is severe, blood transfusion may be required.

Role of NSAIDs in menorrhagia:

The NSAID (non steroidal anti inflammatory drug) used is mefenamic acid 500 mg three times a day with full stomach. This is given for 5-6 days during menstruation in menorrhagia cases of ovulatory cycles, menorrhagia associated with IUCD, and post sterilization menorrhagia. The common side effects of mefenamic acid are nausea, vomiting, headache, dyspepsia, hemolytic anemia etc.

Role of antifibrinolytic drugs:

The drug which was tried with varying result in menorrhagia is epsilon-amino-caproic acid at the dose of 1-3 grams four times a day for 6-7 days. The side effects that are encountered with epsilon-amino-caproic acid are nausea, vomiting, headache, intracranial thrombosis etc.

Menorrhagia is a presenting symptom in many endocrine diseases. In patients with hyperthyroidism, menorrhagia is a frequent symptom, especially in early stage of the disease. In advance stage of hyperthyroidism patients usually have amenorrhea (absence of menstruation). In hypothyroidism menorrhagia is generally seen in the advanced stage of the disease. Menorrhagia is a common symptom in myxedema (disease of hormonal disturbance), especially in women above 40 years of age. In acromegaly (due to excess production of growth hormone in adults) menorrhagia can be a symptom in early stage and in the late stage usually there is amenorrhea.

Iatrogenic causes of menorrhagia:

Menorrhagia may also develop due to use of estrogen for prolonged period for non gynecological condition (especially use of synthetic estrogen prescribed by dermatologists, for relief of symptoms which is not a gynecological problem). The use may be for long duration and at a dose that may be of high. Estrogen is also frequently prescribed by many doctors for menopausal symptoms, and this prescription (of estrogen) may itself cause menorrhagia. Both of the above instances can be regarded as iatrogenic (caused by doctor’s prescription or hospital acquired).

IUCD as a cause of menorrhagia:

IUCD (intrauterine contraceptive device, used as a method of contraception by women), can also cause menorrhagia as seen in recent times. In fairly large percentage of women using IUCD develop menorrhagia in first few periods after insertion of IUCD and in some women the device has to be withdrawn due to continuation of menorrhagia for long duration.

In approximately 15% of cases of tubectomy (sterilization operation in women in which part of Fallopian tube is removed and both ends are ligated to prevent re-canalization) also menorrhagia is seen although the cause is not clear.