Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrhea).
Definition
A normal menstrual cycle is 25–35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. A blood loss of greater than 80 ml or lasting longer than 7 days constitutes menorrhagia (also called hypermenorrhea). Some authors use menorrhagia exclusively when describing excessive quantity and hypermenorrhea for prolonged duration (although most use both terms interchangeably in the clinical setting). In practice this is not usually directly measured by patients or doctors. Menorrhagia also occurs at predictable and normal (usually about 28 days) intervals, distinguishing it from
menometrorrhagia, which occurs at irregular and more frequent intervals. It is possible to estimate the amount of bleeding by the number of tampons or pads a woman uses during her period. As a guide a regular tampon fully soaked will hold about 5ml of blood. One may also have lighter cycles in volume, but blood flow may continue more than seven days thus constituting menorrhagia. An OB/GYN should still be consulted.
Cause
Usually no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. A brief overview of causes is given below, followed by a more formal medical list based on the nature of the menstrual cycle experienced.
Disorders of coagulation
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 pfa col/epi can also be used to ascertain platelet function abnormalities
Excessive build up in endometrial lining
Periods soon after the onset of menstruation in girls (the
menarche) and just before
menopause may in some women be particularly heavy. Hormonal disorders involving the ovaries-pituitary-hypothalamus (the 'ovarian endocrine axis') account for many cases, and hormonal-based treatments may regulate effectively.
The lining of the uterus builds up naturally under the hormonal effects of pregnancy, and an early spontaneous miscarriage may be mistaken for a heavier than normal period.
As women age and move towards menopause, ovulation is delayed and the remaining follicles in the ovaries become resistant to GnRH ( Gonadotropin releasing hormone )secreted by the hypothalamus gland in the brain. Either that or they don't develop an egg, and thus no progesterone is produced. Without progesterone, the estrogen is "unopposed" and keeps building up the lining of the uterus.
During a woman's period, the endometrial lining which is normally shed never gets the signal to stop thickening. It keeps growing and sheds irregularly. Due to the extra thickness, the bleeding is unusually heavy. Less frequently in this age group, too little estrogen causes the irregular bleeding. Most cases of hemorrhagic are due to normal hormonal changes preceding menopause.
Irritation of the endometrium may result in increased blood flow, e.g. from infection (acute or chronic pelvic inflammatory disease) or the contraceptive intrauterine device (note the distinction from the IntraUterine System which is used to treat this condition).
Fibroids in the wall of the womb sometimes can cause increase menstrual loss if they protrude into the central cavity and so thereby increase endometrium's surface area.
Abnormalities of the endometrium such as adenomyosis (so called "internal endometriosis") where there is extension into the wall of the womb gives rise to enlarged tender uterus. Note, true endometriosis is a cause of pain (dysmenorrhoea) but usually not alteration in menstrual blood loss.
Endometrial carcinoma (cancer of the uterine lining) usually causes irregular bleeding, rather than the cyclical pattern of menorrhagia. Bleeding in between periods (intermenstrual bleeding or IMB) or after the menopause (post-menopausal bleeding or PMB) should always be considered suspicious.
Consideration by nature of the menstrual cycle
Excessive menses but normal cycle:
*Painless:
**Fibroids ( leiomyoma )
**Ovarian endocrine disorder (dysfunctional uterine bleeding or DUB)(the most common cause)
**Coagulation defects (rare)
**endometrial carcinoma
**endometrial polyp
*Painful:
**Pelvic inflammatory disease
**Endometriosis
**adenomyosis
Short cycle (<21 days) but normal menses (epimenorrhoea or polymenorrhoea). These are always anovulatory cycles due to hormonal disorders.
Short cycle and excessive menses (epimenorrhagia) due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours.
Excessive menses and long intervals.
*Anovular ovarian disorder due to prolonged oestrogen 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).
Differential Diagnosis
Pregnancy complications:
* Ectopic pregnancy
* Incomplete abortion
* Miscarriage
* Threatened abortion
Nonuterine bleeding:
* Cervical ectropion/erosion
* Cervical neoplasia/polyp
* Cervical or vaginal trauma
* Condylomata
* Atrophic vaginitis
* Foreign bodies
Pelvic inflammatory disease (PID):
* Endometritis
* Tuberculosis
Hypothyroidism
Risk Factors
Obesity
Anovulation
Estrogen administration (without progestogens)
Prior treatment with progestational agents or oral contraceptives increases the risk of endometrial atrophy, but decreases the risk of endometrial hyperplasia or neoplasia
ICD-9 codes
{|border=1 align="center" cellpadding=2
|+
Classification of some causes
|-
! Cause || ICD-9 code
|-
| Polyp of corpus uteri ||
|-
| Endometrial cystic hyperplasia ||
|-
| Other specified disorders of uterus, NEC ||
|-
| Excessive or frequent menstruation ||
|-
| Puberty bleeding ||
|-
| Irregular menstrual cycle ||
|-
| Metrorrhagia ||
|-
| Disorders of menstruation and other abnormal bleedingfrom female genital tract, other ||
|-
| Premenopausal menorrhagia ||
|-
| Postmenopausal bleeding ||
|-
|}
Diagnosis
Pelvic and rectal examination
Pap smear
Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.
Endometrial biopsy to exclude endometrial cancer or atypical hyperplasia
Hysteroscopy
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 then iron tablets may be used to help restore normal hemoglobin levels.
The condition is often treated with hormones, particularly as dysfunctional 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. Fibroids may respond to hormonal treatment, and if they do not, then surgical removal may be required.
Tranexamic acid tablets that may reduce loss by up to 50%. This may be combined with hormonal medication previously mentioned. Anti-inflammatory medication like NSAIDs may also been used, but typically cause only a 30% reduction in flow.
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).
In the UK the use of hysterectomy for menorrhagia has been almost halved between 1989 and 2003. This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.
Medications
These have been ranked by the UK's
National Institute for Health and Clinical Excellence:
First line
* IntraUterine System insertion
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
* Gonadotrophin-releasing hormone (GnRH) agonists (e.g. Goserelin)
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. 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
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
Footnotes
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Category:Menstrual cycle
Category:Noninflammatory disorders of female genital tract
