Menorrhagia

DONE BY: HUGH JACOBS & JANISSA BAKSH

WHAT IS MENORRHAGIA?

Menorrhagia is defined as heavy cyclical menstrual bleeding taking place over several
consecutive cycles,at regular intervals. THERE IS A TOTAL MENSTRUAL BLOOD LOSS OF MORE
THAN 80ml PER MENSTRUATION.

It should be noted that the menstrual cycle is judged as normal by the duration, the amount
and the periodicity of the mentrual flow. Usually the menses last 5-6 days with an occurrence
of every 28 days.

MENORRHAGIA

The average blood loss in a normal menstrual period is 50ml (range 20ml80ml).

About 75 percent of menstrual blood loss occurs during the first 2 days of
bleeding.

Women who lose more than 80ml per menstrual period for six months or more
are likely to develop iron deficiency anemia.

OTHER IMPORTANT DEFINITIONS

MEASUREMENT OF MENSTRUAL BLOOD

LOSS

It has been shown that 50% of women complaining of excessively heavy

periods actually have losses within the normal limits.

The number of pads or tampons soaked used is an unreliable indicator of the

actual amount of bleeding.

An accurate measurment of blood loss can be obtained utilising a Pictorial

Blood Asessment Chart (PBAC). This has a strong correlation with the
measured menstrual loss. It is simple to use and patients are asked to
quantify the amount of blood loss on each item of sanitary protection as
minimal, mild or soaked and it is recorded on a simple chart.

A PBAC score in excess of 100 is equivalent to a blood loss exceeding 80ml per
cycle.

PICTORIAL BLOOD ASESSMENT CHART

PICTORIAL BLOOD ASESSMENT CHART

CONTD

SIGNS AND SYMPTOMS ASSOCATED WITH

MENORRHAGIA

Soaking through one or more sanitary pads or tampons every hour for several
consecutive hours

Needing to use double sanitary protection to control your menstrual flow

Needing to wake up to change sanitary protection during the night

Bleeding for longer than a week

Passing blood clots with menstrual flow for more than one day

Restricting daily activities due to heavy menstrual flow

Symptoms of anemia, such as tiredness, fatigue or shortness of breath

CAUSES OF MENORRHAGIA

PELVIC PATHOLOGY (48.5%) WHICH INCLUDES:

FIBROIDS

ADENOMYOSIS

ENDOMETRIAL POLYPS

ENDOMETRIAL HYPERPLAISA/CARCINOMA

ENDOMETRISOSIS

CAUSES

Uterine Fibroids.These noncancerous (benign) tumors of the uterus appear during your
childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual
bleeding.

Polyps.Small, benign growths on the lining of the uterus (uterine polyps) may cause heavy or
prolonged menstrual bleeding. Polyps of the uterus most commonly occur in women of
reproductive age as the result of high hormone levels.

CAUSES

Adenomyosis.This condition occurs when glands from the endometrium

become embedded in the uterine muscle, often causing heavy bleeding and
painful menses. Adenomyosis is most likely to develop if you're a middle-aged
woman who has had children.

Endometriosis: menorraghia is present in about 75% of all women with

endometriosis. The severity of menorrhagia increases with the increasing
duration of endometriosis. This is more so if theovariesare affected with
endometriotic tissue and there is consequent hormonal disturbance.

CAUSES

CAUSES

CAUSES

CAUSES

CAUSES CONTD

Systemic disorders (1.0%) which includes:

Inherited clotting deficencies

Thrombocytopenia

Chronic liver failure

Hypothyroidism

Abnormal uterine bleeding (50%)

Iatrogenic causes (0.5%) which includes:

Intra uterine contraceptive devices

Warfarin therapy

CAUSES

Inherited bleeding disorders.Some blood coagulation disorders such as Von Willebrand's

disease, a condition in which an important blood-clotting factor is deficient or impaired can
cause abnormal menstrual bleeding.

Medications.Certain drugs, including anti-inflammatory medications and anticoagulants, can

contribute to heavy or prolonged menstrual bleeding.

Intrauterine device (IUD).Menorrhagia is a well-known side effect of using a non-hormonal

intrauterine device for birth control. When an IUD is the cause of excessive menstrual bleeding,
you may need to remove it.

Hormone Imbalance.In a normal menstrual cycle, a balance between the hormones estrogen and
progesterone regulates the buildup of the lining of the uterus (endometrium), which is shed
during menstruation. If a hormone imbalance occurs, the endometrium develops in excess and
eventually sheds by way of heavy menstrual bleeding.

CAUSES

COMPLICATIONS

Iron Deficiency Anemia.Menorrhagia may decrease iron levels enough to increase the risk of
iron deficiency anemia. Signs and symptoms include pale skin, weakness and fatigue. Although
diet plays a role in iron deficiency anemia, the problem is complicated by heavy menstrual
periods.

Most cases of anemia are mild, but even mild anemia can cause weakness and fatigue. Moderate
to severe anemia can also cause shortness of breath, rapid heart rate, lightheadedness and
headaches

Severe pain.Along with heavy menstrual bleeding, you might have painful menstrual cramps
(dysmenorrhea). Sometimes the cramps associated with menorrhagia are severe enough to
require prescription medication or a surgical procedure.

History
In the history a patient complaining of menorrhagia, establish the:

Duration of the complaint

Cyclicity of the menstrual cycle

Exclude other abnormal bleeding episodes (intermenstrual bleeding, post-coital

bleeding).

Exclude overt thyroid disease or clotting disorders

The key to making the diagnosis of menorrhagia is the verification that the
bleeding is regular.

It is important to also discuss the womans contraceptive needs or intention of

having children in the future in order to determine appropriate treatment
options.

History

Duration of
complaint

Cyclicity of
menstrual Cycle

Exclude abnormal
bleeding episodes

Exclude clotting
disorder

Establish regularity
of bleeding

Exclude thyroid
disease

Examination

Examine patient for signs of anaemia

An abdominal and pelvic examination is required to ensure there is no obvious

pelvic pathology, particularly fibroids, before treatment is initiated.

If a cervical smear is due, it would be good practice to take one at the same
time.

A speculum examination will also exclude local cervical lesions or a prolapsing

submucosal fibroid or polyp.

Investigations
1.

Full blood count: -hemoglobinand/orhematocrit to assess for anemia-> to

determine the need for iron therapy. Sickle cell testing is also important in the
Caribbean.

2.

Coagulation Screen: investigations to exclude platelet dysfunction or clotting

disorders in selected patients who usually have within their history episodes of
bleeding tendencies (post-deliveries, following surgical procedures, dental
extraction etc.) or excessive bruising.

3.

Thyroid function test: when the history is suggestive of a thyroid disorder.

4.

Human chorionic gonadotropin (hCG) to exclude pregnancy

Investigations
5.

Pelvic ultrasound: this can be of great benefit in diagnosing endometrial

polyp and fibroids as well as confirming the origin of pelvic masses if found
clinically.

6.

Endometrial biopsy: Endometrial sampling is indicated if there are other

abnormal bleeding patterns in which case endometrial pathology must be
excluded before medical treatment is commenced.

Pipelle
Endometrial
Sampler

Investigations
7.

Hysteroscopy and directed biopsy: hysteroscopy is a useful investigative

procedure in patients in whom a sub-mucous fibroid or polyp is thought to be
present and indeed treatment may be applied at the same time. It is not
necessary to undertake hysteroscopy in all patients with menorrhagia but
perhaps in selective patients where medical treatment has already failed.

Hysteroscope.

Management
When selecting appropriate management for the patient, it is important to
consider and discuss:

the patients preference of treatment;

risks/benefits of each option;

contraceptive requirements:

family complete?

current contraception?

past medical history:

any contraindications to medical therapies for HMB?

suitability for an anaesthetic. Previous surgical history?

Management

INITIAL: Drug treatment is the preferred initial option for women in their
childbearing years as it is reversible and preserves fertility
DRUG

Reduction in MBL
(%)

Side effects

Additional Use(s)

Luteal Progestogens 10-15

Nausea, Vomiting,
bloating, weight
gain, skin rashes

Irregular cycle

Mefenamic acid

20-40

Nausea, vomiting,
diarrhoea, gastric
irritations, rashes

Dysmenorrhoea,
menstrual migraine

Tranexamic acid

45-50

Nausea, vomiting,
tinnitus, dizziness

Oral contraceptive
pill

50

Nausea, weight
gain, thrombosis

FIRST LINE
TREATMENT

Dysmenorrhoea,
irregular cycle

Management

DRUG

Reduction in MBL
(%)

Side effects

Additional Use(s)

Danazol

60-80

Acne, hirsuitism,
voice changes,
muscle cramps

Dysmenorrhoea,
pre-endometrial
ablation

GnRH analogues

90

Climacteric
changes, loss of
libido

Pre-endometrial
ablation

SECOND LINE
TREATMENT

Management

Mefenamic acid

This is a prostaglandin synthetase inhibitor and is a popular first choice of

treatment especially when patients also have dysmenorrhea.
Dosage: It is usually given at a dose of 500 mg three times a day for the duration
of the menses and can be continued over long periods of time. One must keep in
mind the risk of ulceration in the gastro-intestinal tract with this drug.
Benefits: Effective analgesia, hence often the first-line treatment of choice where
dysmenorrhea coexists.
Disadvantages: Contraindicated with a history of duodenal ulcer or severe asthma.

Management

Tranexamic acid

This drug competitively inhibits the activation of plasminogen to plasmin and

counteracts the high fibrinolytic activity in the endometrium that may be one of
the causes of menorrhagia.
Dosage: Doses usually used are 1 g three times daily at the onset of the menses
for the heaviest flow days.
Contraindications: Tranexamic acid is contra-indicated in women with a history
of thrombo-embolic disorders. However, it does not seem to cause thrombosis
per se from large studies of its use.
Benefits: Only requires to be taken on days when
the bleeding is particularly heavy. It is compatible
with ongoing attempts at conception.

Management

Combined oral contraceptive pill (COC)

The pill can be useful in reducing menstrual bleeding. Mode of action is thought to be via
the induction of endometrial atrophy.
Benefits: They also provide effective contraception and help in reducing period pain by
producing anovulatory cycles.
Contraindications: Although the pill is generally well tolerated with minimal sideeffects, patients must be screened for contra-indications to pill usage which include:
Increasing age (>35), increased weight, smoking, personal or family history of breast
cancer and patients who have risk factors for thromboembolism.

Oral Progestogens (Norethisterone)

Commonly prescribed for patients with menorrhagia, however, their efficacy is

questionable especially when used in the short duration. This cyclical progestogen is
effective taken in a cyclical pattern from day 6 to day 26 of the menstrual cycle.
Benefits: It is a safe and effective oral preparation, which can regulate bleeding
pattern.
Disadvantages: It is not a contraceptive and can cause break-through bleeding.

Management

Long-acting Progestogens

Medroxyprogesterone acetate is available as a depot injection for contraception.

Dosage of 150 mg administered every three months initially cause irregular
spotting and bleeding but then in many patients can induce amenorrhoea.
For this reason long-acting progestogens have been tried as treatment for
menorrhagia in patients who also require contraception but more detailed
studies are required.

Management

Progestogen Releasing Intra-uterine Device (Mirena)

The Mirena intra-uterine system, which releases 20 micrograms of Levonorgestrel

daily for up to 5 years, reduces menstrual blood loss by up to 86% by 3 months and up
to 97% by 12 months.
Its possible modes of action are reduction in endometrial prostaglandin synthesis, the
induction of endometrial atrophy and decreased angiogenesis. These devices are now
widely used as the first line treatment of menorrhagia in the absence of intra-uterine
pathology.
Benefits:
It provides contraceptive cover comparable with sterilization.
Recent evidence proves it is effective for associated dysmenorrhoea.
Around 30 per cent of women are amenorrhoeic by one year after insertion.
Disadvantages:
Irregular menses and break-through bleeding for the first 3-9 months after insertion.

Management

Danazol

Danazol is an isoxazol derivative of 17-alpha-ethinyl testosterone which

inhibits ovulation, causes low circulating oestrogen levels and endometrial
atrophy. It has mild androgenic properties.

A dose of 200 mg daily reduces the menstrual blood loss by about 60% but its
incidence of side-effects, weight gain, oily skin and muscle cramps often
inhibits its long-term use

It is imperative that barrier contraception is used during Danazol

administration in non-sterilized women.

Management

GnRH analogues

This group of drug act on GnRH receptors of gonadotrophs in the anterior

pituitary leading to down-regulation, desensitisation and suppression of LH and
FSH release.

This leads to suppression of ovarian function and in the vast majority of patients,
low oestrogen and amenorrhoea result. They are highly effective in reducing
menstrual blood loss.

Also useful as pre-treatment methods prior to endometrial ablation and

myomectomy. (Only with small fibroids (<4cm in diameter)).

These are only used in the short term due to the resulting hypo-oestrogenic state
which predisposes to osteoporosis.

NICE Guidelines

These have been ranked by the UK'sNational Institute for Health and Clinical Excellence
(NICE):

First line

Intrauterine device with progesterone

Second Line

Tranexamic acid

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

Surgical Treatments

Surgical treatment is normally restricted to women for whom medical

treatments have failed.

1) Endometrial Ablation

2) Hysterectomy

Endometrial Ablation

All endometrial destructive procedures employ the principle that

ablation of the endometrial lining of the uterus to sufficient depth
prevents regeneration of the endometrium. The mean reduction in blood
loss associated with this procedure is estimated at around 90 per cent.
The first-generation techniques, including transcervical resection of the
endometrium with electrical diathermy loop or rollerball ablation, have
largely been replaced by newer second-generation techniques.

These include:

Impedence controlled endometrial ablation (Novasure)

Thermal uterine balloon therapy (Thermachoice)

Microwave ablation (Microsulis)

Endometrial Ablation
As a general rule, of all women undergoing endometrial ablation with a secondgeneration technique,

40% will become amenorrhoeic,

40% will have markedly reduced menstrual loss and;

20% will have no difference in their bleeding.

Some authorities have suggested that endometrial ablation is so successful

that all women with HMB should be encouraged to consider it before opting
for hysterectomy.

Hysterectomy

A hysterectomy is the removal of the uterus.

1) Abdominal: This involves an incision which is usually transverse, on the

lower abdomen. A vertical midline incision is sometimes used if the uterus is
markedly enlarged, for example, by fibroids.

2) Vaginal: This involves removal of the uterus and cervix via the vagina with
no abdominal incisions. A subtotal hysterectomy cannot be performed via this
route.

3) Laparoscopic: This category can be subdivided. Laparoscopy-assisted

vaginal hysterectomy (LAVH) is where part of the hysterectomy is performed
laparoscopically and part vaginally. Total laparoscopic hysterectomy (TLH) is
where the whole procedure is performed laparoscopically.

REFERENCES

http://www.mayoclinic.org/diseases-conditions/menorrhagia/basics/definiti
on/con-20021959

http://gynaeonline.com/signs.htm

http://www.slideshare.net/elnashar/excessive-menstrual-bleeding

GYNAECOLOGY by Bharat Bassaw

Gynaecology by Ten Teachers, 19th Edition byAsh Monga &Stephen Dobbs

"CG44 Heavy menstrual bleeding: Understanding NICE guidance"(PDF).

National Institute for Health and Clinical Excellence(UK). 24 January 2007