Menorrhagia

Menorrhagia or hematomunia is an abnormally heavy and prolonged menstrual period at regular intervals. Menorrhagia can be caused by 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 21–35 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. Most common cause include blood disorder or stress-related disorders. 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 uterus sometimes can cause increased menstrual loss if they protrude into the central cavity and 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 uterus gives rise to an 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 cancer
    • 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 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).

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
• Hashimoto's Thyroiditis

Risk Factors

• Obesity or unable to lose weight
• 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

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%. BMJ. 1996 Sep 7;313(7057):579-82 Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid. Bonnar J, Sheppard BL. SourceTrinity College, Department of Obstetrics and Gynaecology, St. James Hospital, Dublin, Ireland.

This may be combined with hormonal medication previously mentioned. Anti-inflammatory medication like NSAIDs may also been used, but typically cause only a 30%^{[citation needed]} 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:^[1]

• 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

1. ^ ^a "CG44 Heavy menstrual bleeding: Understanding NICE guidance" (PDF). National Institute for Health and Clinical Excellence (UK). 24 January 2007. 
2. ^ Reid P, Mukri F (23 Apr 2005). "Trends in number of hysterectomies performed in England for menorrhagia: examination of health episode statistics, 1989 to 2002-3". BMJ 330 (7497): 938–9. doi:10.1136/bmj.38376.505382.AE. PMC 556338. PMID 15695496. 
3. ^ Hurskainen R, Teperi J, Rissanen P, Aalto A, Grenman S, Kivelä A, Kujansuu E, Vuorma S, Yliskoski M, Paavonen J (24 Mar 2004). "Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up". JAMA 291 (12): 1456–63. doi:10.1001/jama.291.12.1456. PMID 15039412. 
4. ^ Istre O, Trolle B (August 2001). "Treatment of menorrhagia with the levonorgestrel intrauterine system versus endometrial resection". Fertil Steril 76 (2): 304–9. doi:10.1016/S0015-0282(01)01909-4. PMID 11476777. 
5. ^ Stewart A, Cummins C, Gold L, Jordan R, Phillips W (January 2001). "The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review". BJOG 108 (1): 74–86. doi:10.1016/S0306-5456(00)00020-6. PMID 11213008. 
6. ^ Feig, Robert L. and Nicole C. Johnson. First Aid for the Obstetrics and Gynecology Clerkship. ISBN 0-07-136423-4.