Menorrhagia

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Practice Essentials

Signs and symptoms

Symptoms related by a patient with menorrhagia often can be more revealing than laboratory tests. A detailed patient history is imperative and should include inquiries about the following:

The physical examination should be tailored to the differential diagnoses suggested by the history. Initial inspection should include evaluation for the following:

General examination should include evaluation of the following:

Pelvic examination should evaluate for the following:

According to an international expert panel, an underlying bleeding disorder should be considered when a patient has any of the following:

See Clinical Presentation for more detail.

Diagnosis

Laboratory studies that may be useful include the following:

Imaging studies and other diagnostic measures that may be helpful include the following:

See Workup for more detail.

Management

Medical therapy should be tailored to characteristics of the patient (eg, age, coexisting medical diseases, family history, and desire for fertility). Agents used include the following:

Surgical management has been the standard of treatment in menorrhagia when the cause is organic or when medical therapy fails to alleviate symptoms. Options for surgical intervention include the following:

Procedures for surgical excision include the following:

See Treatment and Medication for more detail.

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Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.

Background

Menorrhagia is defined as menstruation at regular cycle intervals but with excessive flow and duration and is one of the most common gynecologic complaints in contemporary gynecology. Clinically, menorrhagia is defined as total blood loss exceeding 80 mL per cycle or menses lasting longer than 7 days.[13] The World Health Organization reports that 18 million women aged 30-55 years perceive their menstrual bleeding to be exorbitant.[14] Reports show that only 10% of these women experience blood loss severe enough to cause anemia or be clinically defined as menorrhagia.[13, 15, 16] In practice, measuring menstrual blood loss is difficult. Thus, the diagnosis is usually based upon the patient's history.

A normal menstrual cycle is 21-35 days in duration, with bleeding lasting an average of 7 days and flow measuring 25-80 mL.[17]

Menorrhagia must be distinguished clinically from other common gynecologic diagnoses. These include metrorrhagia (flow at irregular intervals), menometrorrhagia (frequent, excessive flow), polymenorrhea (bleeding at intervals < 21 d), and dysfunctional uterine bleeding (abnormal uterine bleeding without any obvious structural or systemic abnormality).[17]

Nearly 30% of all hysterectomies performed in the United States are performed to alleviate heavy menstrual bleeding.[11] Historically, definitive surgical correction has been the mainstay of treatment for menorrhagia. Modern gynecology has trended toward conservative therapy both for controlling costs and the desire of many women to preserve their uterus.

Heavy menstrual bleeding is a subjective finding, making the exact problem definition difficult. Treatment regimens must address the specific facet of the menstrual cycle the patient perceives to be abnormal, (ie, cycle length, quantity of bleeding). Finally, treatment success is usually evaluated subjectively by each patient, making positive outcome measurement difficult.

Pathophysiology

Knowledge of normal menstrual function is imperative in understanding the etiologies of menorrhagia. Four phases constitute the menstrual cycle, follicular, luteal, implantation, and menstrual.

In response to gonadotropin-releasing hormone (GnRH) from the hypothalamus, the pituitary gland synthesizes follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which induce the ovaries to produce estrogen and progesterone.

During the follicular phase, estrogen stimulation results in an increase in endometrial thickness. This also is known as the proliferative phase.

The luteal phase is intricately involved in the process of ovulation. During this phase, also known as the secretory phase, progesterone causes endometrial maturation.

If fertilization occurs, the implantation phase is maintained. Without fertilization, estrogen and progesterone withdrawal results in menstruation.

Etiologic causes are numerous and often unknown. Factors contributing to menorrhagia can be sorted into several categories, including organic, endocrinologic, anatomic, and iatrogenic.

If the bleeding workup does not provide any clues to the etiology of the menorrhagia, a patient often is given the diagnosis of dysfunctional uterine bleeding (DUB). Most cases of DUB are secondary to anovulation. Without ovulation, the corpus luteum fails to form, resulting in no progesterone secretion. Unopposed estrogen allows the endometrium to proliferate and thicken. The endometrium finally outgrows its blood supply and degenerates. The end result is asynchronous breakdown of the endometrial lining at different levels. This also is why anovulatory bleeding is heavier than normal menstrual flow.

Hemostasis of the endometrium is directly related to the functions of platelets and fibrin. Deficiencies in either of these components results in menorrhagia for patients with von Willebrand disease or thrombocytopenia. Thrombi are seen in the functional layers but are limited to the shedding surface of the tissue. These thrombi are known as "plugs" because blood can only partially flow past them. Fibrinolysis limits the fibrin deposits in the unshed layer. Following thrombin plug formation, vasoconstriction occurs and contributes to hemostasis.

Anatomic defects or growths within the uterus can alter either of the aforementioned pathways (endocrinologic/hemostatic), causing significant uterine bleeding. The clinical presentation is dependent on the location and size of the gynecologic lesion.

Organic diseases also contribute to menorrhagia in the female patient. For example, in patients with renal failure, gonadal resistance to hormones and hypothalamic-pituitary axis disturbances result in menstrual irregularities. Most women in this renal state are amenorrheic, but others also develop menorrhagia. If uremic coagulopathy ensues, it usually is due to platelet dysfunction and abnormal factor VIII function. The resulting prolonged bleeding time causes menorrhagia that can be very tenuous to treat.

Due to the overwhelming factors that can contribute to the dysfunction of either the endocrine or hematological pathways, in-depth knowledge of an existing organic disease is just as imperative as understanding the menstrual cycle itself.

Frequency

United States

While menorrhagia remains a leading reason for gynecologic office visits, only 10-20% of all menstruating women experience blood loss severe enough to be defined clinically as menorrhagia.[16]

Mortality/Morbidity

Infrequent episodes of menorrhagia usually do not carry severe risks to women's general health.

Sex

Only females are affected by menorrhagia.

Age

Any woman of reproductive age who is menstruating may develop menorrhagia. Most patients with menorrhagia are older than 30 years.[17] This is because the most common cause of heavy menses in the younger population is anovulatory cycles, in which bleeding does not occur at regular intervals.[19]

History

Symptoms related by a patient with menorrhagia often can be more revealing than laboratory tests. Considering the lengthy list of possible etiologies that contribute to menorrhagia, taking a detailed patient history is imperative. Inquiries should include the following:

Physical

The physical examination should be tailored to the differential diagnoses formulated by the results of the patient's history.

Causes

Etiologies of menorrhagia are divided into 4 categories, organic, endocrinologic, anatomic, and iatrogenic.

Bleeding disorders

An international expert panel including obstetrician/gynecologists and hematologists has issued guidelines to assist physicians in better recognizing bleeding disorders, such as von Willebrand disease, as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder.[22] Historically, a lack of awareness of underlying bleeding disorders has led to underdiagnosis in women with abnormal reproductive tract bleeding. The panel provided expert consensus recommendations on how to identify, confirm, and manage a bleeding disorder. An underlying bleeding disorder should be considered when a patient has any of the following:

If a bleeding disorder is suspected, consultation with a hematologist is suggested.

Laboratory Studies

Imaging Studies

Other Tests

Procedures

Histologic Findings

Understanding EMB results is essential for any physician treating menorrhagia.

If no tissue is returned after an EMB is performed, most likely the endometrium is atrophic and requires estrogen.

Simple proliferative endometrium is normal and does not require treatment.

Endometrial hyperplasia (except atypical adenomatous) requires progesterone on timed 12-day regimens outlined in the Treatment. Endometrial hyperplasia with atypia (especially atypical adenomatous hyperplasia) generally is considered equivalent to an intraepithelial malignancy, and hysterectomy usually is advised.

Any biopsy that reveals endometrial carcinoma should prompt immediate referral to a gynecologic oncologist for treatment outlined by current oncology protocols associated with the grade and stage of the cancer.

Medical Care

Medical therapy for menorrhagia should be tailored to the individual. Factors taken into consideration when selecting the appropriate medical treatment include the patient's age, coexisting medical diseases, family history, and desire for fertility. Medication cost and adverse effects are also considered because they may play a direct role in patient compliance.[26]

Surgical Care

Surgical management has been the standard of treatment in menorrhagia due to organic causes (eg, fibroids) or when medical therapy fails to alleviate symptoms. Surgical treatment ranges from a simple D&C to a full hysterectomy.

Dilatation and curettage

A D&C should be used for diagnostic purposes. It is not used for treatment because it provides only short-term relief, typically 1-2 months.

This procedure is used best in conjunction with hysteroscopy to evaluate the endometrial cavity for pathology.

It is contraindicated in patients with known or suspected pelvic infection. Risks include uterine perforation, infection, and Asherman syndrome.

Resectoscopic endometrial ablation techniques

Transcervical resection of the endometrium[3]

Transcervical resection of the endometrium (TCRE) has been considered the criterion standard cure for menorrhagia for many years.

This procedure requires the use of a resectoscope (ie, hysteroscope with a heated wire loop), and it requires time and skill.

The primary risk is uterine perforation.

Roller-ball endometrial ablation[4]

Roller-ball endometrial ablation essentially is the same as TCRE, except that a heated roller ball is used to destroy the endometrium (instead of the wire loop).

It has the same requirements, risks, and outcome success as TCRE.

Satisfaction rates are equal to those of TCRE.

Endometrial laser ablation

Endometrial laser ablation requires Nd:YAG equipment and optical fiber delivery system.

The laser is inserted into the uterus through the hysteroscope while transmitting energy through the distending media to warm and eventually coagulate the endometrial tissue.

Disadvantages include the expense of the equipment (high), the time required for the procedure (long), and the risk of excessive fluid uptake from the distending media infusion and irrigating fluid.

This technique has largely been replaced by the nonresectoscopic systems (discussed below).

Nonresectoscopic endometrial ablation techniques

Thermal balloon therapy[5, 6]

A balloon catheter filled with isotonic sodium chloride solution is inserted into the endometrial cavity, inflated, and heated to 87°C for 8 minutes.

Uterine balloon therapy cannot be used in irregular uterine cavities because the balloon will not conform to the cavity.

Studies report a 90% satisfaction rate and a 25% amenorrhea rate. Long-term studies are ongoing.

Heated free fluid[7]

HydroThermAblator (HTA) is an office procedure in which normal saline is infused into the uterus via the hysteroscope.

The solution is heated to 194°F (90°C) for 10 minutes under direct visualization.

This procedure requires only local anesthesia.

HTA may be used in patients with irregularly shaped endometrial cavities and/or fibroids.

Vaginal and skin burns are the most reported complications.

Cryoablation[8]

Cryoablation is the use of liquid nitrogen to freeze the endometrium. The procedure is performed in approximately 10 minutes under ultrasonographic guidance.

Patients usually experience 1 week of watery vaginal discharge postprocedure.

Risks include perforation and suboptimal ablation of the entire uterine cavity.

Microwave endometrial ablation alternative[9]

Microwave endometrial ablation (MEA) uses high-frequency microwave energy to cause rapid but shallow heating of the endometrium.

Microwaves are selected so that they do not destroy beyond 6 mm in depth.

MEA requires 3 minutes of time and only local anesthetic. It is proving to be as effective as TCRE.

This procedure was developed and has been used in Europe since 1996.

Radiofrequency electricity[8]

NovaSure system is a detailed microprocessor-based unit with a bipolar gold mesh electrode array.

It contains a system for determining uterine integrity based upon the injection of CO2.

The device is placed transcervically, the array is opened and electrical energy is applied for 80-90 seconds, desiccating the endometrium.

Endometrial ablation or resection preparation

A trial of medical therapy should have failed in patients considered for this therapy.

The endometrium should be properly sampled and evaluated before surgery.

Patients should be pretreated with danazol or a GnRH analogue for 4-12 weeks before surgery to atrophy the endometrium, reducing surgical difficulty and time.

Success rates are similar to laser ablation techniques.

A 2005 Cochrane Review (updated in 2009) concluded that "overall the existing evidence suggests that success rates and complication profiles of newer techniques of ablation compare favourably with TCRE, although technical difficulties with new equipment need to be ironed out."[9, 35]

Surgical techniques

Myomectomy[10]

Myomectomy can be useful in women who wish to retain their uterus and/or fertility.

Since myomectomy can be associated with large blood loss, this procedure is often reserved for cases of a single or few myomas.

Risks include large blood loss or recurrence.

Hysterectomy[11, 12]

Hysterectomy provides definitive cure for menorrhagia.

This procedure is more expensive and results in greater morbidity than ablative procedures.

The mortality rate ranges from 0.1-1.1 cases per 1000 procedures.

The morbidity rate is usually 40%.

Risks include those usually associated with major surgery.

A study by Roberts et al reviewed the cost effectiveness of first-generation and second-generation endometrial ablative techniques, hysterectomy, and the levonorgestrel-releasing intrauterine system (Mirena) for the treatment of heavy menstrual bleeding.[36] Although the authors did not define "heavy menstrual bleeding," their analysis concluded that the most cost-effective initial treatment for menorrhagia that yielded the best quality of life was hysterectomy.

Medication Summary

Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.


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Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.

Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpartum does not respond to progesterone therapy, while anovulatory bleeding worsens with high-dose estrogen.


View Image

Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpa....


View Image

Flow chart continued from Media file 2.


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Flow chart continued from Media files 2 and 3.

Naproxen (Anaprox, Naprelan, Naprosyn)

Clinical Context:  Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Diclofenac (Cataflam)

Clinical Context:  Inhibits PG synthesis by decreasing activity of enzyme cyclooxygenase, which in turn decreases formation of PG precursors.

Class Summary

Block formation of prostacyclin, an antagonist of thromboxane, which is a substance that accelerates platelet aggregation and initiates coagulation. Prostacyclin is produced in increased amounts in menorrhagic endometrium. Because NSAIDs inhibit blood prostacyclin formation, they might effectively decrease uterine blood flow.

Dienogest/estradiol valerate (Natazia)

Clinical Context:  Negative feedback decreases GnRH amounts resulting in reduced LH and FSH secretion from the pituitary gland and anovulation. Indicated for treatment of heavy menstrual bleeding not caused by any diagnosed conditions of the uterus in women who choose an oral contraceptive for contraception.

Class Summary

OCPs containing estrogen and progestin used to treat acute hemorrhagic uterine bleeding.

Medroxyprogesterone (Provera)/megestrol acetate/19-nortestosterone derivative

Clinical Context:  Provera: Short-acting synthetic progestin. Works as an antiestrogen by minimizing estrogen effects on target cells. Endometrium is maintained in an atrophic state. Effective against hyperplasia and has modest effects on serum lipids (ie, lowering HDL)

Megestrol acetate: May be substituted for Provera. Is active against hyperplasia without significantly altering serum lipid levels.

Derivatives of 19-nortestosterone: Potent progestins used in oral contraceptives. Have partial androgenic properties and lower HDL cholesterol levels.

Class Summary

Occasional anovulatory bleeding that is not profuse or prolonged can be treated with progestins, antiestrogens given in pharmacologic doses. Inhibit estrogen-receptor replenishment and activate 17-hydroxysteroid dehydrogenase in endometrial cells, converting estradiol to the less-active estrone.

Leuprolide (Lupron)

Clinical Context:  Suppresses ovarian and testicular steroidogenesis by decreasing LH and FSH levels.

Class Summary

Work by reducing concentration of GnRH receptors in the pituitary via receptor down-regulation and induction of postreceptor effects, which suppress gonadotropin release. After an initial gonadotropin release associated with rising estradiol levels, gonadotropin levels fall to castrate levels, with resultant hypogonadism. This form of medical castration is very effective in inducing amenorrhea, thus breaking the ongoing cycle of abnormal bleeding in many anovulatory patients.

Danazol (Danocrine)

Clinical Context:  Synthetic steroid analog with strong antigonadotropic activity (inhibits LH and FSH) and weak androgenic action. Competes with androgen and progesterone at receptor level, resulting in amenorrhea within 3 mo.

Class Summary

Certain androgenic preparations have been used historically to treat mild-to-moderate bleeding, particularly in ovulatory patients with abnormal uterine bleeding. Use might stimulate erythropoiesis and clotting efficiency. Alters endometrial tissue so that it becomes inactive and atrophic.

Desmopressin (DDAVP)

Clinical Context:  Has been used to treat abnormal uterine bleeding in patients with coagulation defects. Transiently elevates factor VIII and von Willebrand factor.

Class Summary

Indicated in patients with thromboembolic disorders.

Conjugated equine estrogen (Premarin)

Clinical Context:  Only controls bleeding acutely but does not treat underlying cause. Appropriate long-term therapy can be administered once the acute episode has passed.

Class Summary

Effective in controlling acute, profuse bleeding. Exerts a vasospastic action on capillary bleeding by affecting the level of fibrinogen, factor IV, and factor X in blood and platelet aggregation and capillary permeability. Estrogen also induces formation of progesterone receptors, making subsequent treatment with progestins more effective.

Complications

Prognosis

With proper workup, diagnosis, treatment, and follow-up care, prognosis is excellent.

Author

Julia A Shaw, MD, MBA, FACOG, Assistant Professor and Residency Program Director, Department of Obstetrics and Gynecology, Yale School of Medicine; Medical Director, Yale-New Haven Hospital Women's Center

Disclosure: Nothing to disclose.

Coauthor(s)

Howard A Shaw, MD, MBA, FACOG, Associate Clinical Professor of Obstetrics and Gynecology, Yale University School of Medicine; Chairman, Department of Women's and Children's Services, Hospital of Saint Raphael

Disclosure: Athena Feminine Technologies Ownership interest Consulting

Specialty Editors

Thomas Michael Price, MD, Associate Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Disclosure: Clinical Advisors Group Consulting fee Consulting; MEDA Corp Consulting Consulting fee Consulting; Gerson Lehrman Group Advisor Consulting fee Consulting; Adiana Grant/research funds PI

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Disclosure: Nothing to disclose.

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Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.

Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.

Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpartum does not respond to progesterone therapy, while anovulatory bleeding worsens with high-dose estrogen.

Flow chart continued from Media file 2.

Flow chart continued from Media files 2 and 3.

Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.

Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpartum does not respond to progesterone therapy, while anovulatory bleeding worsens with high-dose estrogen.

Flow chart continued from Media file 2.

Flow chart continued from Media files 2 and 3.