para>Metrorrhagia: irregular or frequent flow, noncyclic
Menometrorrhagia: frequent, excessive, irregular flow in amount and duration (menorrhagia plus metrorrhagia)
Polymenorrhea: frequent flow, cycles of ≤21 days
Intermenstrual bleeding: bleeding between regular menses
Abnormal uterine bleeding (AUB): abnormal endometrial bleeding of hormonal and other causes related to pregnancy, anovulation (estrogen breakthrough), estrogen or progesterone excess or withdrawal, thyroid disorders, adenomyosis, endometriosis, malignancy, as well as infection and bleeding disorders
System affected: reproductive
Epidemiology
Prevalence
- The prevalence of menorrhagia is estimated at 30% in the general population during reproductive years and increases with age.
Menarche to menopause; ’ Ό50% of cases occur in patients age >40 years.
Menorrhagia is fairly common in adolescence and in the perimenopausal period.
In adolescence, irregular or heavy bleeding due to anovulation and immaturity of the hypothalamic " pituitary " ovarian axis is common.
In adolescence, severe menorrhagia may be associated with a bleeding disorder up to 40% of the time, with platelet function defects and von Willebrand disease being the most common.
Pediatric Considerations
Genital bleeding before puberty can result from trauma, foreign bodies, vaginal infection due to abuse, or exogenous hormone administration but is not considered menorrhagia by definition.
Pregnancy Considerations
Bleeding in pregnancy is not menorrhagia. But menorrhagia in a period a couple days late could be a miscarriage.
Etiology and Pathophysiology
- Hypothyroidism if regular menses
- Endometrial proliferation//hyperplasia
Anovulation; oligo-ovulation frequently associated with heavy, prolonged, painful periods; called menorrhagia if occurring regularly
Ovarian tumor or other estrogen-producing tumor
Prolonged use of oral combination pill formulated to allow menses
Polycystic ovarian syndrome, (PCOS) (although menses often irregular)
Local factors:
Abnormal endometrial prostaglandin levels
Endometrial polyps
Endometrial neoplasia
Adenomyosis/endometriosis
Uterine myomata (fibroids)
Intrauterine device (IUD)
Uterine sarcoma
- Coagulation disorders:
Thrombocytopenia, platelet disorders
von Willebrand disease, factor deficiencies
Leukemia
Ingestion of aspirin/acetylsalicylic acid or anticoagulants
Renal failure/dialysis leading to uremic platelet dysfunction
Risk Factors
- Obesity due to estrogen excess
- Infertility/nulliparity
- Anovulation due to chronic unopposed estrogen stimulation (menses usually irregular)
- Family history of endometrial or colon cancer
General Prevention
Combined oral contraceptives help prevent menorrhagia when progesterone is dominant. Lower estrogen doses result in less menstrual bleeding. Ibuprofen inhibits prostaglandin production without permanently affecting platelets and is also noted to decrease blood loss at menses. Progesterone-only contraceptives reduce blood loss but can often convert menorrhagia to unpredictable (although lighter) uterine bleeding.
Commonly Associated Conditions
Endometriosis, adenomyosis, fibroids, low-grade infection
Diagnosis
History
- Excessive menstrual flow is defined subjectively and varies greatly from woman to woman (1).
- Useful features: Regular bleeding substantially heavier than usual flow (or >80 mL/cycle, if quantified, or changing pads or tampons every 1 " 2 hours as quantified by patient) lasting >7 days.
- Symptoms that suggest cycles are ovulatory:
Regular menstrual interval
Midcycle pain (mittelschmerz)
Premenstrual symptoms: breast soreness, mood changes
- Abdominal pain or cramps at other times of the cycle may be associated with structural causes:
Myomas
Polyps
Ovarian tumors
Endometriosis
- Symptoms that may indicate a more general bleeding disorder:
- Review of medications
Physical Exam
- Hirsutism, acne, or obesity may accompany chronic anovulation such as with PCOS.
- Signs of nongenital or general bleeding, bruising, petechiae
- Pelvic/rectal examination to detect/exclude other causes of bleeding:
Cervical or vaginal bleeding
Pelvic or adnexal masses
Signs of pelvic infection
Urethral trauma
Gastrointestinal bleeding
Differential Diagnosis
- Pregnancy complications
- Nonendometrial bleeding
- Pelvic inflammatory disease
Diagnostic Tests & Interpretation
Initial Tests (lab, imaging)
- Pregnancy test: Always exclude pregnancy first.
- CBC with differential to assess severity of blood loss and to rule out thrombocytopenia and leukemia
- In selected cases:
Thyroid-stimulating hormone test, prolactin
If suspected anovulation, DHEAS
Coagulation panel, with platelet function testing if screen is abnormal
Creatinine, BUN to rule out uremia
Serum progesterone: 5 " 20 ng/mL (15.9 " 63.6 nmol/L) in luteal phase, <1 ng/mL (<3.18 nmol/L) in follicular phase or anovulatory cycle
If infectious cause is suspected, aerobic genital culture, wet and KOH preps for microscopic evaluation, or bacterial vaginosis panel and PCR for gonorrhea and chlamydia
- Transvaginal ultrasonography can help distinguish bleeding caused by structural abnormalities versus anovulatory bleeding via assessment of endometrial stripe.
- Abdominopelvic ultrasonography to evaluate suspected adnexal masses or myomas
- Saline infusion sonography for evaluation of small lesions frequently missed on transvaginal ultrasound
- Hysteroscopy to evaluate structural abnormalities more closely (2)[A]
- CT may be used to investigate potentially malignant pelvic masses if needed after ultrasound.
Diagnostic Procedures/Other
- Endometrial biopsy detects hyperplasia, dysplasia, or atrophy. If done before expected menses, it may also help confirm the diagnosis of anovulation or luteal phase defect.
- All women older than age 40 years with unexplained menorrhagia or older than age 35 years with unexplained menometrorrhagia should undergo an endometrial biopsy to rule out cancer.
- Progestins used before endometrial biopsy may cause decidualization but rarely obscure correct diagnosis and often are valuable as an empiric test.
Treatment
Medication
First Line
- For acute control of severe bleeding:
Estrogen, conjugated (Premarin): 25 mg IV q4h up to 6 doses or 10 " 20 mg/day PO in four divided doses until bleeding abates; not for use in patients with estrogen contraindications (give with antiemetics).
Tranexamic acid 650 mg (3) 3 daily for up to 5 days, expensive but as effective, nonestrogenic but not for those with clotting disorder
- For less severe bleeding (usual case) or after control of acute bleeding has been achieved:
Medroxyprogesterone acetate (Provera): 10 " 30 mg/day for 5 " 10 days
Any combination oral contraceptive (i.e., usually a high-dose oral contraceptive) 1 tablet QID for 5 " 7 days (usually poorly tolerated, give with antiemetic)
- To prevent heavy bleeding in subsequent cycles:
Second Line
- Nonsteroidal prostaglandin-synthetase inhibitors (e.g., naproxen, mefenamic acid, ibuprofen) can reduce blood loss ’ Ό25% with ovulatory cycles and reduce dysmenorrhea.
- Norethindrone acetate (Aygestin): 2.5 " 10 mg/day for 10 " 21 days/month if anovulatory
- Levonorgestrel intrauterine system (Mirena IUD) causes amenorrhea in around 50% and irregular spotting in the other half. A few women experience heavier bleeding.
Surgery/Other Procedures
- Endometrial ablation by laser or electrosurgical, microwave, or thermal means is a conservative alternative to hysterectomy and usually successful, although some patients require additional therapy in the long term (4)[B].
- Uterine artery embolization is a conservative method to treat leiomyomata (5,6)[A].
- Hysterectomy when indicated to treat coexisting conditions (myomas, endometrial dysplasia) or for bleeding unresponsive to other measures
Inpatient Considerations
Admission Criteria/Initial Stabilization
- Bleeding leading to orthostatic hypotension
- Hematocrit <25% or hemoglobin <8 and symptomatic
- Most cases can be managed as outpatient in an office or emergency department.
- Rule out pregnancy complications and nonuterine bleeding.
- Treat severe or life-threatening bleeding acutely:
Circulatory support; transfusion, if necessary
IV Premarin (estrogen), tranexamic acid PO
Curettage, if necessary
Uterine tamponade and hysterectomy in extreme cases
Ongoing Care
Follow-up Recommendations
Proceed to identify the underlying cause of bleeding, and treat to prevent recurrence:
- Hormonal therapy
- Dilatation and curettage for cases that fail to respond to hormone therapy
- Consider endometrial ablation, uterine fibroid embolization, or hysterectomy in persistent cases in which fertility is not a concern (4).
- Specific treatment for neoplasia, polyps, systemic disease
- Patients desiring fertility may also need appropriate treatment for anovulation, endometriosis, and myomas (surgical) (1,4,6)[A].
Patient Monitoring
Medical treatment of hyperplastic/dysplastic endometrium should be followed by a repeat biopsy to confirm that histologic structure has returned to normal.
Diet
Iron supplementation may help correct for increased blood loss.
Patient Education
Information about side effects of medications should be provided as well as risks and benefits of procedures.
Prognosis
Most patients with hormonal imbalances will respond to hormonal manipulation.
Complications
- Anemia
- Asherman syndrome from vigorous dilation and curettage
- Estrogen may precipitate acute, intermittent porphyria or cholestatic jaundice in susceptible patients.
- Prolonged treatment with Depo-Provera may lead to bone loss, but clinical significance is uncertain; rapid regain after discontinuation is usual.
- Even with acute bleeding, estrogen should not be used in patients with coronary artery disease, significant carotid narrowing, active liver disease, thrombophilias, estrogen-dependent cancer history, or pregnancy.
References
1.Matteson KA, Munro MG, Fraser IS. The structured menstrual history: developing a tool to facilitate diagnosis and aid in symptom management. Semin Reprod Med. 2011;29(5):423 " 435. [View Abstract]2.Sweet MG, Schmidt-Dalton TA, Weiss PM, et al. Evaluation and management of uterine bleeding in premenopausal women. Am Fam Physician. 2012;85(1):35 " 43. [View Abstract]3.Bouchard P. Current and future medical treatments for menometrorrhagia during the premenopause. Gynecol Endocrinol. 2011;27(Suppl 1):1120 " 1125. [View Abstract]4.Karimi-Zarichi M, Dehghani-Firoozabadi R, Tabatabaie A, et al. A comparison of the effect of levonorgestrel IUD with oral medroxyprogesterone acetate on abnormal uterine bleeding with simple endometrial hyperplasia and fertility preservation. Clin Exp Obstet Gynecol. 2013;40(3):421 " 424. [View Abstract]5.Osayande AS, Mehulic S. Diagnosis and initial management of dysmenorrhea. Am Fam Physician. 2014;89(5):341 " 346. [View Abstract]6.van der Kooij SM, Bipat S, Hehenkamp WJ, et al. Uterine artery embolization versus surgery in the treatment of symptomatic fibroids: a systematic review and metaanalysis. Am J Obstet Gynecol. 2011;205(4):317.e1 " 317.e18. [View Abstract]
Additional Reading
See Also
- Abnormal Pap and Cervical Dysplasia; Amenorrhea; Cervical Malignancy; Cervical Polyps; Cervicitis, Ectropion, and True Erosion; Abnormal (Dysfunctional) Uterine Bleeding; Dysmenorrhea; Menopause; Polycystic Ovarian Syndrome (PCOS); Uterine Myomas
- Algorithm: Menorrhagia (Excessive Bleeding)
Codes
ICD10
- N92.0 Excessive and frequent menstruation with regular cycle
- N92.1 Excessive and frequent menstruation with irregular cycle
- N93.8 Other specified abnormal uterine and vaginal bleeding
ICD09
- 626.2 Excessive or frequent menstruation
- 626.8 Other disorders of menstruation and other abnormal bleeding from female genital tract
- 626.6 Metrorrhagia
SNOMED
- 386692008 Menorrhagia (finding)
- 314631008 menometrorrhagia (finding)
- 19155002 Dysfunctional uterine bleeding (finding)
- 52754008 polymenorrhea (finding)
Clinical Pearls
- Menorrhagia is defined as an excessive amount or duration of menstrual flow at regular intervals.
- Pregnancy should be ruled out as part of the initial evaluation.
- Because endometrial carcinoma is a significant cause of bleeding in women age >35 years, an endometrial biopsy to rule out endometrial carcinoma is recommended if the bleeding remains undiagnosed, especially if not confined to regular cyclic menses.
- Remember that estrogen should not be used in patients with coronary artery disease, carotid stenosis, liver disease, thrombophilias, and family history of estrogen-dependent cancer (breast and endometrial).