Menorrhagia

Published on 06/06/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 2404 times

Chapter 117 Menorrhagia

INTRODUCTION

Description: Menorrhagia—heavy menstrual flow—is generally divided into primary and secondary. Secondary is caused by (secondary to) some clinically identifiable cause; primary is caused by a disturbance of prostaglandin production. Menorrhagia is generally distinguished from acute vaginal bleeding (most often associated with pregnancy and pregnancy complications).
Prevalence: Ten percent to 15% of women experience excessive menstrual flow.
Predominant Age: Reproductive.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Secondary—see differential diagnosis following. Primary—overproduction, or an imbalance in the relative ratios of uterine prostaglandins (prostaglandin E2, prostaglandin I2, and thromboxane A2). Some evidence suggests that patients with primary menorrhagia may also have increased fibrinolysis, further enhancing a tendency to bleed.
Risk Factors: Diabetes, obesity, or chronic anovulation (which place the patient at higher risk for endometrial hyperplasia or malignancy), systemic disease, or metabolic disturbances associated with bleeding dyscrasias.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Menstrual loss of greater than 80 mL, which may result in anemia
• Excessive soiling or numbers of menstrual hygiene products used (objective studies have shown a poor correlation with the actual measured blood loss)
• Anemia (in the absence of other causes of anemia, anemia is diagnostic for menstrual volumes of greater than 80 mL per cycle)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Uterine leiomyomata (one third of patients will have menorrhagia)
• Adenomyosis (40% to 50% have menorrhagia)
• Endometrial or cervical polyp(s)
• Endometrial hypertrophy or hyperplasia
• Endometrial cancer
• Cervical lesions (including cancer)
• Infection (cervicitis, chronic endometritis)
• Intrauterine contraceptive device use
• Chronic anovulation
• Nongynecologic causes include blood dyscrasia or coagulopathy, hypothyroidism, leukemia, hepatic or renal disease, systemic lupus erythematosus, thyroid disease
• Benign or malignant tumors of ovary (rare)

Associated Conditions: Anemia, toxic shock syndrome (prolonged tampon use).

Workup and Evaluation

Laboratory: Complete blood count, pregnancy test, clotting profile (as indicated).
Imaging: Pelvic ultrasonography (based on diagnosis being considered—limited to the detection of secondary sources).
Special Tests: None indicated.
Diagnostic Procedures: History, physical, and laboratory evaluation.

Pathologic Findings

Based on cause.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, nutritional support.
Specific Measures: Based on cause. Nonsteroidal anti-inflammatory agents have been shown to reduce menstrual loss in primary menorrhagia. When taken for this indication, they must be taken continuously for the duration of flow. In patients with intractable menorrhagia or patients being prepared for extirpative surgery or endometrial ablation, therapy with gonadotropin-releasing hormone (GnRH) agonists may be considered. Uterine artery embolization has been advocated for selected patients.
Diet: No specific dietary changes indicated. Iron supplementation if indicated (either ferrous sulfate or gluconate, 300 mg PO two to three times a day).
Activity: No restriction.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP095 (Abnormal Uterine Bleeding), AP116 (Menstrual Hygiene Products), AP046 (Dysmenorrhea).

Drug(s) of Choice

Conjugated estrogen (20 to 25 mg IV) or intramuscular progestins have been widely advocated for acute bleeding.
Oral estrogen (conjugated estrogen 2.5 mg, micronized estradiol 3 to 6 mg) may be given acutely every 2 hours until the bleeding slows or stops. Estrogen therapy is then maintained for 20 to 25 additional days, with a progestin added for the last 10 days of treatment.
Combination oral contraceptives containing estradiol and norgestrel (Ovral, four tablets a day for 3 to 5 days or until bleeding stops, followed by one daily for the duration of the pack or four tablets the first day, followed by three for 1 day, two the next day, and then one daily for the remainder of the package).
For long-term therapy, levonorgestrel-releasing intrauterine devices have been shown to be effective in reducing menstrual blood loss.
Contraindications: Therapy should not be instituted until the possibility of pregnancy has been evaluated and a working diagnosis has been established.
Precautions: See individual agents.
Interactions: See individual agents.

Alternative Drugs

When the endometrium is reasonably intact, high-dose progestin may be used to stop acute uterine bleeding (medroxyprogesterone acetate 10 mg PO three times a day or IM depot medroxyprogesterone acetate, 150 to 300 mg). Nonsteroidal anti-inflammatory agents have been shown to reduce menstrual loss 30% to 50% when taken for the duration of flow (e.g., meclofenamate sodium 100 mg PO three times a day during flow, mefenamic acid [Ponstel] 250 mg PO three times a day during flow). Levonorgestrel-releasing intrauterine devices have been shown to provide a comparable reduction in menstrual blood loss.

image

FOLLOW-UP

Patient Monitoring: Normal health maintenance. Watch for anemia. Patients who are at risk for endometrial hyperplasia or neoplasia, or those who do not respond to initial therapy, may require endometrial biopsy, hysteroscopy, or diagnostic curettage.
Prevention/Avoidance: Based on cause. If contraception is desired, oral combination contraceptives, or continuously dosed progestins (orally, by injection, or as a medicated intrauterine device), or oral contraceptives (either monophasic or polyphasic) are reasonable options. In patients with intractable menorrhagia or in patients being prepared for extirpative surgery or endometrial ablation, therapy with gonadotropin-releasing hormone agonists may be considered for a maximum of 6 months. Cost and side effects limit this approach.
Possible Complications: Anemia, hypovolemia (acute loss).
Expected Outcome: Based on cause; most patients respond to conservative therapy. The most successful therapy is directed at the underlying cause. Once acute control has been gained, cyclic estrogen/progestin therapy should be continued for an additional 3 months. During this interval, additional diagnostic studies may be considered and plans may be laid for long-term management, should it be necessary.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy.
ICD-9-CM Codes: 626.2, 626.3 (Pubertal), 627.0 (Premenopausal).

REFERENCES

Level I

Anderson ABM, Haynes PJ, Cuillebaud J, et al. Reduction of menstrual blood loss by prostaglandin synthetase inhibitors. Lancet. 1976;1:774.

Bhattacharya S, Cameron IM, Parkin DE, et al. A pragmatic randomised comparison of transcervical resection of the endometrium with endometrial laser ablation for the treatment of menorrhagia. Br J Obstet Gynaecol. 1997;104:601.

Gannon MJ, Holt EM, Fairbank J, et al. A randomised trial comparing endometrial resection and abdominal hysterectomy for the treatment of menorrhagia. BMJ. 1991;303:1362.

Halmesmaki K, Hurskainen R, Teperi J, et al. The effect of hysterectomy or levonorgestrel-releasing intrauterine system on sexual functioning among women with menorrhagia: a 5-year randomised controlled trial. BJOG. 2007;114:563.

Hehenkamp WJ, Volkers NA, Donderwinkel PF, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial. Am J Obstet Gynecol. 2005;193:1618.

Showstack J, Lin F, Learman LA, et alMs Research Group. Randomized trial of medical treatment versus hysterectomy for abnormal uterine bleeding: resource use in the Medicine or Surgery (Ms) trial. Am J Obstet Gynecol. 2006;194:332.

Level II

Amso NN, Stabinsky SA, McFaul P, et al. Uterine thermal balloon therapy for the treatment of menorrhagia: the first 300 patients from a multi-centre study. International Collaborative Uterine Thermal Balloon Working Group. Br J Obstet Gynaecol. 1998;105:517.

Brown PM, Farquhar CM, Lethaby A, et al. Cost-effectiveness analysis of levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding. BJOG. 2006;113:797.

Busfield RA, Farquhar CM, Sowter MC, et al. A randomised trial comparing the levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding. BJOG. 2006;113:257.

Chullapram T, Song JY, Fraser IS. Medium-term follow-up of women with menorrhagia treated by rollerball endometrial ablation. Obstet Gynecol. 1996;88:71.

Garside R, Stein K, Wyatt K, Round A. Microwave and thermal balloon ablation for heavy menstrual bleeding: a systematic review. BJOG. 2005;112:12.

Goldenberg M, Sivan E, Bider D, et al. Endometrial resection vs. abdominal hysterectomy for menorrhagia. Correlated sample analysis. J Reprod Med. 1996;41:333.

Hald K, Klow NE, Qvigstad E, Istre O. Laparoscopic occlusion compared with embolization of uterine vessels: a randomized controlled trial. Obstet Gynecol. 2007;109:20.

Khaund A, Moss JG, McMillan N, Lumsden MA. Evaluation of the effect of uterine artery embolisation on menstrual blood loss and uterine volume. BJOG. 2004;111:700.

Meyer WR, Walsh BW, Grainger DA, et al. Thermal balloon and rollerball ablation to treat menorrhagia: a multicenter comparison. Obstet Gynecol. 1998;92:98.

Rauramo I, Elo I, Istre O. Long-term treatment of menorrhagia with levonorgestrel intrauterine system versus endometrial resection. Obstet Gynecol. 2004;104:1314.

Reid PC, Virtanen-Kari S. Randomised comparative trial of the levonorgestrel intrauterine system and mefenamic acid for the treatment of idiopathic menorrhagia: a multiple analysis using total menstrual fluid loss, menstrual blood loss and pictorial blood loss assessment charts. BJOG. 2005;112:1121.

Related posts:

Cervical Incompetence Forceps-Aided Delivery Anorectal Fistula Vaginitis: Bacterial (Nonspecific) and Bacterial Vaginosis Rh Incompatibility Irregular Menstrual Periods