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When having your period leads to a blood transfusion

SINGAPORE — For most women, menstruation is no more than a minor inconvenience. For Ms Goh Hwee Ling, however, severe menstrual bleeding after the birth of her first child caused a major disruption in her daily activities and made her anaemic.

About 30 to 40 per cent of women will experience heavy menstrual bleeding (HMB), a form of abnormal uterine bleeding, at some point in their lives. Photo: iStock

About 30 to 40 per cent of women will experience heavy menstrual bleeding (HMB), a form of abnormal uterine bleeding, at some point in their lives. Photo: iStock

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SINGAPORE — For most women, menstruation is no more than a minor inconvenience. For Ms Goh Hwee Ling, however, severe menstrual bleeding after the birth of her first child caused a major disruption in her daily activities and made her anaemic.

For two to three days each month, the teacher’s life would revolve around changing sanitary pads every hour to manage her heavy flow.

“Even then, some menstrual blood might still drip onto the floor,” said Ms Goh, who is in her forties.

“Whenever my period arrived, I had to take an extra change of clothes and underwear to work and I often found myself stuck in the ladies’ washing up after myself. As a teacher, it was very inconvenient for me. I had to ask another teacher to take over my class, and pray that the ladies’ was not too far away.”

Ms Goh’s experience is considered mild compared to some cases managed by doctors here.

About 30 to 40 per cent of women will experience heavy menstrual bleeding (HMB), a form of abnormal uterine bleeding, at some point in their lives, said Associate Professor Fong Yoke Fai, head of the benign gynaecology division in the National University Hospital’s (NUH) department of obstetrics and gynaecology.

The figure may be higher as HMB is often underreported. Many women suffer for years before seeking help, he said.

Some women experience such severe menstrual bleeding that they end up in the emergency department and require multiple blood transfusions.

Studies show that almost one in five hospital admissions for HMB occur after the women are brought into the emergency department after fainting from anaemia, said Assoc Prof Fong.

A study last year by NUH found that 33 of the 177 cases of patients hospitalised for HMB were admitted through the accident and emergency (A&E) department. Almost nine in 10 of the emergency admissions required blood transfusions.

Every week, about two to three patients are admitted to the Singapore General Hospital’s (SGH) emergency department for abnormal heavy period or anaemia due to heavy menstrual blood loss.

A woman’s blood count can become so low as a result of the heavy menstrual bleeding that it can cause heart failure, said Associate Professor Yong Tze Tein, senior consultant at SGH’s department of obstetrics and gynaecology, which sees about 10 to 20 women with complaints about heavy periods per week.

People with anaemia can become breathless or tired, suffer from hair loss and brittle nails, or even become depressed, said Assoc Prof Yong.

Assoc Prof Fong once encountered a patient who was so traumatised by her heavy menstrual bleeding that she took medication to halt her periods.

“At one point, the patient’s bleeding occurred right in front of us while in the hospital and she felt faint and breathless. We had to give her at least two units of blood to stabilise her blood level,” he said.



Cases of abnormal uterine bleeding are likely to become more common in Singapore, with women in their child-bearing years having fewer children than the previous generations, said Assoc Prof Fong.

According to him, many underlying causes of HMB and abnormal uterine bleeding are related to the menstruation hormone cycle. The most common causes seen in older women are fibroids and endometriosis (a condition in which the layer of tissue that normally lines the inside of the uterus grows outside of it), he said.

“Today, many women have far more years of cycles than their mothers and grandmothers, who were protected by more pregnancies and more years of breastfeeding,” he said.

Other causes include adenomyosis (where the lining of the womb infiltrates into the womb muscle, causing the womb to enlarge), cervical and, occasionally, ovarian cancer. But sometimes, no cause is found, said SGH’s Assoc Prof Yong.



Despite severe symptoms, many women with HMB choose to keep mum about the problem. They are either embarrassed to talk about it or think the symptoms are just part of ageing or being a woman, said Assoc Prof Fong.

“Sometimes, women are very resilient and they delay seeing doctors because the bleeding may be painless. What they do is try to cope – from buying a longer sanitary pad to using two simultaneously. I even had a patient who wore diapers,” said Assoc Prof Yong.

There may be a cultural element. While women in the United States see their gynaecologists more often and usually from a younger age (such as their teens or early twenties) for contraceptives and regular check-ups, many women here do not do so until they are pregnant, trying to conceive or encounter serious problems, said Assoc Prof Fong.

“In the West, especially in the United States, doctors see fewer cases because more women use contraception, oral and hormone-releasing intrauterine devices (IUDs), which also protect against many of the underlying causes of HMB,” he said.




By the time HMB sufferers finally see a doctor, they often require more extensive and complicated treatment.

Most underlying causes of HMB, such as fibroids and endometriosis, worsen if left untreated and can cause serious health issues like infertility, warned Assoc Prof Fong, who has seen patients with fibroids the size of a large full-term baby.

“Besides pain, and bladder and bowel symptoms due to the pressure, some of these large abdominal masses also compress on the venous return from the legs. This can result in blood clots in the leg, and they are potentially life-threatening if they dislodge and get carried into the lungs,” said Assoc Prof Fong.

Up to a third of patients who present late may need to have their wombs removed, he said.

“In many cases, emergency admissions and surgery could probably have been avoided had the condition been diagnosed early and treated with medication such as oral hormonal therapies or hormone-releasing IUDs,” added Assoc Prof Fong.

Treatment depends on what’s causing the symptoms of heavy menstrual bleeding, and how far it has progressed.

There are currently many effective medical treatments, said Assoc Prof Yong.

For instance, there is an oral medication to control bleeding and shrink fibroids and endometriosis, she said. Other options include tranexamic acid that is taken during periods to reduce the flow.

Hormonal causes of HMB typically respond well to oral contraceptives, hormone-releasing intrauterine systems (IUS) or even nonsteroidal anti-inflammatory drugs, said Assoc Prof Fong.

In the case of fibroids or endometriosis, which do not require urgent surgical intervention, progestogen-only pills or progestogen-loaded intrauterine contraceptive device are some methods that can be used to treat the heavy menstrual bleeding, said Assoc Prof Fong. Progestogen is a steroid hormone.

He advised women to see a gynaecologist if they experience unusually heavy or painful periods for three or more cycles.

“Ideally, women should get into the habit of seeing a gynaecologist for regular check-ups. Single and married women over 30 should go for PAP smear and HPV (human papillomavirus) tests at least every five years, and consider having ultrasound scans if they have symptoms,” said Assoc Prof Fong.

While Ms Goh’s anaemia was never severe enough to warrant a blood transfusion, she was prescribed iron supplements. Last year, she started using a hormone-releasing IUS to manage her condition and reduce her menstrual bleeding.

“I no longer have to endure the rigmarole that I did for the last 10 years. My advice to other women experiencing HMB is to look for the cause of the problem instead of suffering in silence. I wish I had done this earlier,” said Ms Goh.




The clinical definition of heavy menstrual bleeding (HMB) is blood flow of 80ml or more.

If you answer “yes” to one or more of these questions, you may have HMB:

a. At peak flow, do you soak through one or more sanitary pads or tampons every hour for several consecutive hours?

b. Do you need to use double sanitary protection, such as a pad and a tampon to control your menstrual flow?

c. Do you need to wake up to change sanitary protection during the night?

d. Do you often bleed for longer than a week?

e. Do you pass blood clots larger than the new 50 cent coin?

f. Are your daily activities restricted due to heavy menstrual flow?

g. Do you experience tiredness, fatigue, dizziness or shortness of breath during your menses? (These are symptoms that might indicate anaemia)


Source: Associate Professor Fong Yoke Fai from National University Hospital.

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