Abstract: Menorrhagia is the common condition found in the reproductive life of a female. It is the term now employed to signify an increased or immoderate flow of the menses or profuse menstruation. There are fearful complications of such disorders that may tax the allopath. Those dealing with a large number of these cases view their utter hopelessness. Homoeopathic practitioners are conscious of the wonderful virtues of homoeopathic medicines to arrest even the rapid loss of vital fluid itself and are mindful of the special and characteristic indications.
Key words: Menorrhagia, Homoeopathy, Minton’s Uterine therapeutics.
Menorrhagia limits normal activities, affects quality of life, and causes anaemia in two-thirds of women with objective menorrhagia (loss of 80 ml blood per cycle). Prostaglandin disorders may be associated with idiopathic menorrhagia and with heavy bleeding due to fibroids, adenomyosis, or use of intrauterine devices (IUDs). Fibroids have been found in 10% of women with menorrhagia overall and in 40% of women with severe menorrhagia, but half of women having a hysterectomy fo menorrhagia are found to have a normal uterus.
Menorrhagia is a common gynaecological condition in day to day practice. It is a condition which may arise from functional, pathological, systemic disease. The term Menorrhagia is not the disease but one presentation of a disease.
- Polymenorrhea: Menstrual bleeding at interval of fewer than 21 days.
- Oligomenorrhea: Menstrual bleeding at interval of more than 35 days.
- Metrorrhagia: Bleeding at irregular, acyclic from uterus
- Menometrorrhagia: Heavy, irregular bleeding.
- Hypomenorrheoa: Scanty menstrual bleeding lasting less than 2 days.
Definition: Menorrhagia is defined as cyclic bleeding at normal intervals, where the bleeding is either excessive in amount i.e. menstrual flow more than 80 ml, or duration of menstrual flow more than 7 days or both. (Syn: Hypermenorrhea)
Menotaxis is often used to denote prolonged bleeding.
Puberty menorrhagia: menstrual blood loss greater than 80 ml before the age of 20 yrs.
CAUSES OF MENORRHAGIA: Menorrhagia can be functional or organic
- Dysfunctional uterine bleeding
- Fibroid especially sub mucus
- Tubo-ovarian mass
- Pelvic endometriosis
- IUCD insertion
- Tubercular endometritis
- Retroverted uterus
- Granulosa cell tumour
- Endometrial polyp
Systemic causes include:
- Liver dysfunction
- Cushing syndrome
- Idiopathic thrombocytopenic purpura
- Von willebrand disease
- Medication: for thinning of blood
- Emotional upset
Diagnosis: History of onset, duration of flow, Amount of bleeding, character of blood (passage of big clots), use of increased number of sanitary pads, and the level of Haemoglobin gives a true idea regarding correct diagnosis and magnitude of menorrhagia in absence any other sources of bleeding in body.
PATHOPHYSIOLOGY OF MENORRHAGIA IN PELVIC CAUSES
Menorrhagia occurs because of following three basic causes
- Due to pelvic congestion
- Increased surface area
- Hyperplasia of endometrium
PATHOPHYSIOLOGY IN PARTICULAR DISEASE CONDITION
(a) Uterine Fibroid: Menorrhagia is a most important symptom in cases of the sub mucus fibroid. The patient may present to physician with menorrhagia as a chief complaint in such cases. Menorrhagia occurs in cases of fibroid due to combination of following mechanism
- Increased surface area
- Interference with normal uterine contractility
- Congestion and dilatation of subadjacent endometrial venous plexuses
caused by tumour
- Endometrial hyperplasia
- Pelvic congestion
Clinical features: Progressive menorrhagia in every subsequent period. The patient is generally nulliparous may be suffering from infertility, mass can be felt per abdominally or on bimanual examination.
Investigation: USG to confirm the diagnosis
Hysteroscopy in case of sub mucus fibroid
(b) Pelvic Endometriosis: It is a condition where the functioning endometrium is present in sites other than uterine mucosa. The cause of menorrhagia in endometriosis is increase pelvic blood flow i.e. pelvic congestion.
Clinical features: Menorrhagia is associated with progressively increasing secondary dysmenorrhoea, the females suffering from this problem commonly nulliparous and infertile of age between 30 to 45 yrs, on physical examination (bimanual examination) palpable tender nodules in Pouch of Douglas, fixed retroverted uterus or unilateral or bilateral adnexal masses of varying size.
Investigation: Laparoscopy “powder burn” or “match stick” appearance (though laparoscopy is diagnostic but USG can give idea regarding the endometriosis by showing recurrent ovarian cyst, fibrosis, adhesion of pelvic structures)
(c) Adenomyosis: When ectopic endometrial tissue found in myometrium it is called as adenomyosis or endometriosis interna. Though this is also a type of endometriosis but most of presentation of patient is opposite to the pelvic endometriosis. In adenomyosis the causes of menorrhagia are
- Increased uterine cavity
- Endometrial hyperplasia
- Inadequate uterine contraction
Clinical features: Menorrhagia associated with progressive secondary dysmenorrhoea, Regular firm mass (felt on bimanual examination). But it is common in multiparous female above age of 40 yrs.
Investigation: USG shows enlarge uterus with heterogenous myometrial echostructure
(d) Dysfunctional Uterine Bleeding: It is the state of abnormal uterine bleeding without any detectable pelvic pathology due to anovulatory cycles. In DUB the basic fault is in ovary due to disturbance of rhythmic secretion of the gonadotrophins. There is slow increase in oestrogen level causing endometrial hyperplasia in absence of growth limiting progesterone. When withdrawal of FSH occurs there occurs bleeding for long period in asynchronous sequence because of lack of endometrial compactness in absence of progesterone.
Clinical feature: Painless menorrhagia with no Nothing abnormal findings in bimanual or per abdomen examination but in some cases bulky uterus may be the finding.
Investigation: Actually DUB is exclusion diagnosis when all the possible causes have been investigated nothing abnormality found.
Endometrial curettage confirms the diagnosis (word of caution: During premenopausal period diagnostic curettage is mandatory to exclude endometrial malignancy.)
Histology shows various type of hyperplasia:
- Cystic hyperplasia which the normal response to excess of oestrogen least malignant.
- Adenomatous hyperplasia: here it is difficult to distinguish it from atypical hyperplasia and significant chances association with subsequent carcinoma.
- Atypical hyperplasia: most dangerous risk of carcinoma is directly proportional to degree of atypicalibity of pathology
(e) IUCD Insertion: Menorrhagia is the commonest complication mainly occurs in first and second generation IUCD insertion. IUCD causes foreign body reaction in uterus causing cellular inflammation and congestion causing menorrhagia.
Clinical features: History of excessive bleeding since IUCD insertion with previously normal menses, per speculum examination reveals visible thread of IUCD.
Investigation: When thread is not visible USG confirms presence of IUCD in uterus.
Menorrhagia is indication for IUCD removal.
(f) Endometritis: Inflammation of endometrium is an important cause of menorrhagia. The menorrhagia occurs due to pelvic congestion, endometrial hyperplasia.
Clinical features: Menorrhagia, infertility, purulent discharge per vagina. There may be past history of pulmonary T.B.
Investigation: Uterine curettage done during the week preceding menstruation. (For evaluation of infertility HSG is routinely advised test but its use is contraindicated as there are chances of spread of infection and reactivation of old lesion)
(g) Tubo- ovarian mass: When chronic inflammation of fallopian tubes and ovaries commonly occurs together to form a mass it is called as tubo-ovarian mass. Generally it occurs as sequel of acute pelvic inflammatory condition except in tuberculosis where it starts in this form.
Clinical features: Menorrhagia, Bilateral pelvic pain, abnormal vaginal discharge, tenderness in fornices increased on movement of cervix with palpable irregular mass in lateral fornix
(h) Ovarian Granulosa Tumour: Most common tumour is epithelial cell tumour 90% and Non epithelial cell tumour 10%. It includes granulosa cell tumour type of sex cord cell tumour. In this condition granulosa cell hyperplasia occur which secrets oestrogen there will be excessive secretion of oestrogen results in endometrial hyperplasia and menorrhagia.
Clinical features: History of precocious puberty, menorrhagia.
Investigation: Uterine curettage
COMPLICATION OF MENORRHAGIA:
Anaemia is the most important complication of menorrhagia. The level of Hb% in women is already less than the man which is due to menstruation. If the women suffer from menorrhagia then it may leads to further fall in Hb % and severe complication. Whereas in tropical country anaemia is severe because the Hb % of females living in tropical region is low because of diseases like malaria, infestation of hookworm, and dietary deficiency of iron.
Character of blood in menorrhagia (abnormal bleeding): In abnormal bleeding there is relative deficiency of fibrinolytic enzymes which liquefy the menstrual blood. Hence of blood in abnormal uterine haemorrhage are generally clotted as compared to fluid blood in normal bleeding.
So if we ask a question about the character of blood then it may give us some clue about the abnormal uterine bleeding and menorrhagia.
Miasmatic Concept of Abnormal Bleeding:
Latent Psora: Menstruation too copious, of too long duration, too watery, connected with various bodily ailments. The menses flow for five, six, eight and more days, but only intermittently, a little flow every six, twelve, twenty-four hours, and then they cease for half or whole days, before more is discharged. The menses flow too strongly, for weeks, or return almost daily. Menses of watery blood or of brown clots of blood. (Chronic disease).
Sycosis: Menstrual flow, offensive large, clotted, stringy large clots, dark even black flow discharge are generally acrid and excoriating and produces vesicles excoriation, which are a source of great annoyance to the patient- offensive like stale fish. Many ovarian or tubular symptoms that develop during the menses, are dependent more in Sycosis than any other miasm. (Chronic miasm by J. Henry Allen)
Pseudopsora: Menstrual abnormality in tubercular patients exhaustive and often a prolonged and copious flow, usually bright red blood, seldom offensive may be painless but are always exhaustive, inducing anaemia. Cholera like symptoms, such as nausea, vomiting, extreme purging, from bowel, with sweat generally tubercular in origin. (Chronic miasm by J. Henry Allen)
Syphilis: Syphilis seldom attacks the ovaries or uterus by (Chronic miasm J. Henry Allen)
But the exact miasmatic diagnosis of abnormal bleeding will be carried by overall case taking, clinical symptoms, and pathological examination of patient.
Diathesis: Haemorrhagic diathesis
Treatment of Menorrhagia by Homoeopathy:
As discussed previously, menorrhagia is an outward reflection of the internal disease which may be acute due to some exiting cause or chronic in nature due op miasms, diathesis and constitutional dyscrasia, which can be successfully treated and managed by homoeopathy on the basis of homoeopathic principles. The importance of menstrual symptoms like menorrhagia, amenorrhoea etc. in female disorder are mentioned by Dr Samuel Hahnemann in Aphorism 89 and Footnote 1 of aphorism 94 of Organon of medicine.
- 89 When the patient (for it is on him we have chiefly to rely for a description of his sensations, except in the case of feigned diseases) has by these details, given of his own accord and in answer to inquiries, furnished the requisite information and traced a tolerably perfect picture of the disease, the physician is at liberty and obliged (if he feels he has not yet gained all the information he needs) to ask more precise, more special questions In women, note the character of menstruation and other discharges, etc.(6th edition)
- 94 Footnote 1: In chronic diseases of females it is specially necessary to pay attention to pregnancy, sterility, sexual desire, accouchements, miscarriages, suckling, and the state of the menstrual discharge. With respect to the last-named more particularly, we should not neglect to ascertain if it recurs at too short intervals, or is delayed beyond the proper time, how many days it lasts, whether its flow is continuous or interrupted, what is its general quality, how dark is its colour, whether there is leucorrhoea before its appearance or after its termination, but especially by what bodily or mental ailments, what sensations and pains, it is preceded, accompanied or followed; if there is leucorrhoea, what is its nature, what sensations attend its flow, in what quantity it is, and what are the conditions and occasions under which it occurs?
Repertorial Study on Menorrhagia
Rubrics related with Menorrhagia in Minton Uterine Therapeutics:
Rubrics related with Menorrhagia are included in chapter of menstruation under subsection Time and Quantity of Discharge. This section is very much similar in its content to the rubric “Menses” in other general repertories.
This section includes specifications of menses under:
- Time and quantity of discharge.
- Character of menstrual discharge.
- Before menstruation.
- During menstruation.
- After menstruation
Rubrics related with Menorrhagia under Section Time and Quantity of Menstrual Discharge are:
Profuse and protracted
Profuse and of short duration
Rubrics Related To Exciting Cause
Profuse after short concussion: Arn.
Profuse after delay: Lach.
Profuse after dancing: Crocus, erig., secale
Profuse after exciting, the least: Calc.c
Profuse after riding: Amm c.
Profuse at night: Amm c., amm m., cycl., mang c., zinc.
Profuse during lactation: Calc. c. Silicea.
Profuse during menopause: Act rac., anath., bovis., crocus., helon., lach., nux.v., plumb., secale., sepia., ust.
Profuse during motion: Crocus, erig., Sabina., secale.
Profuse during passage of hard stool: Iod., lyc.
Profuse during thunderstorm: nat.c.
Profuse first day only: Nat. c.
Profuse from fall: Arn.
Profuse from induration of uterus: Carbo. an., con., iod., kreos.
Profuse from overexertion: Crocus, millef., nit. ac., trill.
Profuse from shocks: Arn.
Profuse from strains: Rhus.
Rubric Related to Constitution
Profuse in the women, blonde: Apocy., chel., ferr.
Profuse in the women, chlorotic: Calc.c chin., cycl., ferr., helon., sepia.
Profuse in the women, delicate: Amm. c. ars., calc.c., carbo an., ferr., helon., sepia.
Profuse in the women, dropsical: Apis. Apocy., ars., senecio.
Profuse in the women, frivolous: Apis.
Profuse in the women given to religious reveries: Sulph.
Profuse in women, hysterical: Cham., cocc., coff., con., hyos., ign., ipec., phos, plat., puls., Sabina,.
Profuse in women lean: Phos. Secale.
Profuse in the women, leucoplegmatic: Ant. c., calc. c., cycl., puls., sulph.
Profuse in women, loquacious: Stram.
Profuse in women married especially: Secale.
Profuse in the women, nervous: Cham., coff., ign., nux. v., plat., puls., secale, sepia.
Profuse in the women, phthisical: Calc. c., kali. c., phos., sang., stann.
Profuse in the women, psoric: Sulph.
Profuse in the women, rheumatic: Act. rac., bry., rhus.
Profuse in the women, scrawny: Secale.
Profuse in the women, scrofulous: Calc. c., caust., iod., nat.m., silicea., sulph.
Profuse in the women, slender: Phos.
Profuse in the women, subject to violent grief: Ign.
Profuse in the women, tall: Phos.
Profuse in women, thin: Apis , phos., secale.
Profuse in the women, withered up: Arg. n.
Profuse in the women, with chapped skin: Hepar.
Profuse in the women, with dark hair: Acon., kali. c., sepia.
Profuse in the women, with dropsical condition: Apis, apocy., ars., hell., senecio.
Profuse in the women, with facial neuralgia: Stann.
Profuse in the women, with fine skin: Sepia
Profuse in women, with glandular affection: Carbo. an.
Profuse in the women with organic disease of uterus: Ars., kreos.
Profuse in the women tendency to cerebral congestion: Bell.
Profuse in women, with waxy pale face: Ars
Profuse in the women, who lead sedentary lives: Acon. nux. v.
Profuse in women who sigh and sob much: Ign.
Rubrics Related With Modalities (Circumstantial)
Profuse when frightened: Ust.
Profuse when riding: Amm. c.
Profuse when riding in cold air: Amm. c.
Profuse when rising from seat: Cocc. Ust.
Profuse when standing: Amm. c. mang. c
Profuse when sweeping: Crocus
Profuse when walking: Amm. c., crocus, erig., lil tig., nat.m., sabina, ust., zinc.
Rubric Related with Time Modalities
Profuse in the daytime: Caust., coff., cycl., ham., nat.m., puls.
Profuse in the morning: Carbo an., borax, bovis.
Rubrics Related With Concomitants
Profuse with burning across the sacrum: Carbo. v.
Profuse with coldness of the body: Coff.
Profuse with desire for sexual embrace: Agar.
Profuse with distention of the abdomen: China, cocc., crocus.
Profuse with faintness: acon, apis, chin., cocc., crocus.
Profuse with pain in the back: Amm. c. amm. m. bell., caust., secale.
Homoeopathic Therapeutics of Menorrhagia
Uterine active or passive haemorrhage after a fall or rough riding with bearing down pain in back but no mental anxiety. Menses flow dark profuse with soreness of abdomen after blow on ovary or fall, all the suffering < at menstrual period. Prostration out of proportion to blood loss. It checks haemorrhages. Chronic effects of mechanical injuries.
Menses profuse active or passive bright red clotted. With oppressed breathing stitches from navel to uterus. Persistent nausea and vomiting with almost all complaints, nausea not better by vomiting. Patient is thirstless with almost all complaints. Tongue clean or slightly coated. Stomach feels relaxed, as if hanging down. Bright red, gushing haemorrhage from all orifices.
Haemorrhages profuse, bright red, fluid. Congestions. Bruised soreness. Painless haemorrhage after labour or abortion, after great exertion, after miscarriages, preventive in PPH. Menses early, profuse, protracted, with colicky pain in abdomen. HAEMORRHAGES – Profuse, bright, red, painless especially from injury, without fever, without anxiety, without nausea.
Sycotic growths, fibroids, warts. Menses-profuse, bright, early, discharge of blood between periods with sexual excitement. Pain from sacrum to pubis, from below upwards shooting up the vagina. Retained placenta from atony of uterus, promotes expulsions of moles or foreign bodies from uterus. Tendency to miscarriage at 3rd month.
THLASPI BURSA PASTORIS:
Anti haemorrhagic, anti uric acid remedy. Haemorrhage- profuse, passive from every outlet of body, blood dark, clotted. Taste in mouth like bad eggs. Craves Buttermilk. Female genitalia-Metrorrhagia; in chlorosis, after abortion, labour or miscarriage, at climateric, with cancer uteri [Phos, Ust.] Metrorrhagia with violent uterine colic, too frequent and copious menses. Every alternate period is profuse. Menses- too early, too profuse, protected (eight, ten or fifteen days) tardy in starting; first day merely a show, second day colic and vomiting and haemorrhage with large clots. Uterine haemorrhage with cramps expulsion of clots. Scarcely recovers from one period before another one begins. Menses and leucorrhoea leaves a fast stain.
Gushing haemorrhage with sensation as if the bones of hips, back or thighs be forced apart; with faintness and sinking at stomach. Menses every two weeks. Hemorrhagic tendency with great faintness and dizziness. Uterine haemorrhage and sensation as though hips and back were falling to pieces (or as if bones of hips, back and thighs were forced apart) >tight bandaging. Especially useful in menses every 2 weeks, lasting a week and very profuse, flooding with fainting, dim sight, palpitations, noises in ears, cold extremities and thirst. Desire for water or disgust for everything except cold water.
Haemorrhage from all orifices-profuse, bright red flow. Especially, useful in uterine haemorrhages, menorrhagia or metrorrhagia due to overlifting or false step. -Haemorrhages. A strain in loins, a false step brings on a profuse flow of bright blood (from bowels). Female genitalia-Menses-Early, profuse, prolonged (lasting nearly the whole month), bright red, particularly in females troubled with itching of nose and nightly restlessness. Profuse flow, cold extremities, pallor of surface. Uterine haemorrhage caused by overlifting; during puerperal stage. Post-partum haemorrhage; blood thin and pale. Extremities-Fingers seem swollen.
Menstruation: Too early, profuse and protracted. Least excitement causes menses to return discharge – bright red or light coloured. Before menstruation: Voluptuous dreams. Swelling and sensitiveness of breast. During menstruation: Heat in vertex. Cold damp feet. After menstruation: Pleasurable sensation parts. Mucous leucorrhoea resembling milk. Calcarea appropriate for complicated cases of pulmonary and uterine cases, women with scrofulous diathesis hysterical women at climacteric of leuco phlegmatic constitution.
Menstruation: Too early, too profuse and too long lasting. Leucorrhoea in place of menstruation. Suppression of menses with burning along the spine. Before menstruation: leucorrhoea with weeping mood. During menstruation: Anxious with sensation as if something creeping out from corner. She is very sleepy, scarcely able to keep awake. Blue rings around the eyes. Violent colic as if cut with knife. Sensation of emptiness in abdomen. After menstruation: blue rings around the eyes. Stitches from vagina to utrus. Milky, mucous, or acrid blistering leucorrhoea. Aversion to sexual intercourse. Particularly adapted to tall thin dark haired women, disposed to be stoop shouldered, to weak, nervous persons, and to young girls who grow too fast.
Menstruation: generally delayed, scanty menses or intermittent, regular but scanty and feeble. Profuse during climacteric period. Before menstruation: great desire for open air. Cardalgia at each menstrual nisus. Leucorrhoea three days before menses having greenish stain. Labour like pain in left ovarian region. During menstruation: great desire for open air, burning at vertex. Pains subsides when flow becomes free. Menstrual colic in the left ovary. Can not bear any pressure not even of her clothing in uterine region. Unhappy waking during morning. After menstruation: diarrhea.
Menstruation: too early, too profuse, dark coloured, thick, brownish, offensive and runs into leucorrhoea. Before menstruation: Crampy pain in hypogastrium with pain in small of back and nape of neck just before menses. During menstruation: Great weakness scarcely able to breath and has lie down. Cramp in hypogastrium as if it would burst. Violent bearing down pains in the lower part of abdomen as though everything would be pressed out. After menstruation: leucorrhoea of greenish mucus, or brown water offensive.
Menstruation: too late and too scanty or too early, profuse flooding, with excited circulation, discharge of partly, fluid partly black clotted blood. Menses intermittent; they ceases for two three days and then return discharge of pale and watery blood. Before menstruation: great feeling of wretchedness, mental depression disappears when menses. Leucorrhoea like watery milk or like boiled starch corroding the parts. During menstruation: discharge of watery blood. Excited circulation with glowing redness of face menses
Menorrhagia is a common clinical condition which may be found functionally, or related to some uterine pathology or due to any systemic pathology. In homoeopathy, we treat the patient not the disease, hence we should take each and every case of menorrhagia as a unique one and treat each patient as an individual. If we follow strict homoeopathic principles then we will definitely achieve success in this condition.
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