Menorrhagia

Menorrhagia is a menstrual period with excessively heavy flow and falls under the larger category of abnormal uterine bleeding (AUB).^[1]

Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, anovulation, bleeding disorders, or cancer of the reproductive tract. Initial evaluation aims at figuring out pregnancy status, menopausal status, and the source of bleeding.

Treatment depends on the cause, severity, and interference with quality of life.^[2] Initial treatment often involve contraceptive pills. Surgery can be an effective second line treatment for those women whose symptoms are not well-controlled.^[3] Approximately 53 in 1000 women are affected by AUB.^[4]

Signs and symptoms

A normal menstrual cycle is 21–35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. Menorrhagia is defined as total menstrual flow >80ml per cycle, or soaking a pad/tampon every 2 hours or less.^[1] Deviations in terms of frequency of menses, duration of menses, or volume of menses qualifies as abnormal uterine bleeding. Bleeding in between menses is also abnormal uterine bleeding and thus requires further evaluation.

Complications of Menorrhagia could also be the initial symptoms. Excessive bleeding can lead to anemia which presents as fatigue, shortness of breath,and weakness. Anemia can be diagnosed with a blood test.

Causes

Usually no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. However, there are known causes of abnormal uterine bleeding that need to be ruled out. Most common causes based on the nature of bleeding is listed below followed by the rare causes of bleeding (i.e. disorders of coagulation).

Consideration

• Excessive menses but normal cycle:
  • Painless:
    • Fibroids (leiomyoma) — fibroids in the wall of the uterus cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrial surface area.
    • Coagulation defects (rare) — with the shedding of an endometrial lining's blood vessels, normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities
    • Endometrial cancer (cancer of the uterine lining) — bleeding can also be irregular, in between periods, or after the menopause (post-menopausal bleeding or PMB)
    • Endometrial polyp
  • Painful:
    • Pelvic inflammatory disease
    • Endometriosis - extension of the endometrial tissue outside of the uterus tries to shed causing painful and abnormal bleeds
    • Adenomyosis - extension of the endometrial tissue into the wall of the uterus tries to shed causing painful and abnormal bleeds
    • Pregnancy related complication (i.e. miscarriage)
• Short cycle (less than 21 days) but normal menses.These are always anovulatory cycles due to hormonal disorders.
• Short cycle and excessive menses due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours.
• Excessive menses and long intervals.
  • Anovulatory ovarian disorder due to prolonged estrogen production.
  • This may occur following prolonged continuous courses of the combined oral contraceptive pill (e.g. where several packets are taken without a withdrawal gap in order to defer menstruation).
• Systemic causes: thyroid disease, excessive emotional/physical stress

Diagnosis

Diagnosis is largely achieved by obtaining a complete medical history followed by physical exam and ultrasound. If need be laboratory tests or Hysteroscopy may be performed at the discretion of the medical provider. The following are a list of diagnostic procedures that medical professionals may use to identify the cause of the abnormal uterine bleeding.

• Pelvic and rectal examination to ensure that bleeding is not from lower reproductive tract (i.e. vagina, cervix) or rectum
• Pap smear to rule out cervical neoplasia
• Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.^[5]
• Endometrial biopsy to exclude endometrial cancer or atypical hyperplasia
• Hysteroscopy
• TSH and T4 dosage to rule out hypothyroidism ^[6]

Treatment

Where an underlying cause can be identified, treatment may be directed at this. Clearly heavy periods at menarche and menopause may settle spontaneously (the menarche being the start and menopause being the cessation of periods).

If the degree of bleeding is mild, all that may be sought by the woman is the reassurance that there is no sinister underlying cause. If anemia occurs due to bleeding then iron tablets may be used to help restore normal hemoglobin levels.^[1]

The condition is often treated with hormones, particularly as abnormal uterine bleeding commonly occurs in the early and late menstrual years when contraception is also sought. Usually, oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System (IUS) may be used.^[7][8] Fibroids may respond to hormonal treatment, and if they do not, then surgical removal may be required.

Tranexamic acid tablets that may also reduce loss by up to 50%.^[9] This may be combined with hormonal medication previously mentioned.^[10]

Anti-inflammatory medication like NSAIDs may also be used. NSAIDs are the first-line medications in ovulatory menorrhagia, resulting in an average reduction of 20-46% in menstrual blood flow.^[11] For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.^[12]

A definitive treatment for menorrhagia is to perform hysterectomy (removal of the uterus). The risks of the procedure have been reduced with measures to reduce the risk of deep vein thrombosis after surgery, and the switch from the front abdominal to vaginal approach greatly minimizing the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids may be dealt with by local removal (myomectomy). A further surgical technique is endometrial ablation (destruction) by the use of applied heat (thermoablation).^[13]

In the UK the use of hysterectomy for menorrhagia has been almost halved between 1989 and 2003.^[14] This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS^[15][16] which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.^[17]

Medications

These have been ranked by the UK's National Institute for Health and Clinical Excellence:^[5]

• First line
  • Intrauterine device with progesterone
• Second Line
  • Tranexamic acid an antifibrinolytic agent
  • Non-steroidal anti-inflammatory drugs (NSAIDs).
  • Combined oral contraceptive pills to prevent proliferation of the endometrium
• Third line
  • Oral progestogen (e.g. norethisterone), to prevent proliferation of the endometrium
  • Injected progestogen (e.g. Depo provera)
• Other options
  • Gonadotropin-releasing hormone agonist

Surgery

• Dilation and curettage (D&C) is no longer performed for cases of simple menorrhagia, having a reserved role if a spontaneous abortion is incomplete
• Endometrial ablation
• Uterine artery embolisation (UAE)
• Hysteroscopic myomectomy to remove fibroids over 3 cm in diameter

Complications

Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia.^[2] Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration.

References

Further reading

• Continuous Identification of Research Evidence (collaborative of the WHO, and US CDC & Johns Hopkins Hospital) - Search of Evidence about the IUS
• Abnormal vaginal bleeding National Guideline Clearinghouse
• Menorrhagia - Menstrual Abnormalities and Abnormal Uterine Bleeding Menstrual Abnormalities and Abnormal Uterine Bleeding - Armenian Medical Network
• Abnormal uterine bleeding/dysfunctional uterine bleeding. Intracorp - Public For Profit Organization. 2005. Various pagings. NGC:004390
• Working group on inherited bleeding disorders rbdd - Rare Bleeding Disorders database
• Project Red Flag Information About Women and Bleeding Disorders
• Adenomyosis Information from MayoClinic.com
• Working group on menorrhagia Menorrhagia and other gynaecological problems in women affected by bleeding disorders