Menorrhagia

Published on 23/06/2015 by admin

Filed under Complementary Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 2268 times

Chapter 189 Menorrhagia

Tori Hudson, ND

Diagnostic Summary

• Excessive menstrual bleeding—blood loss greater than 80 mL—occurring at regular cyclic intervals (cycles are usually but not necessarily of normal length).

• May be due to dysfunctional uterine bleeding (no organic cause); often due to local lesions (e.g., uterine myomas [fibroids], endometrial polyps, endometrial hyperplasia, endometrial cancer, adenomyosis, and endometritis); other causes are bleeding disorders and hypothyroid.

The diagnosis begins with the history and physical examination. The following tests and procedures are performed for diagnosis and management on an as-needed basis: pelvic examination, pelvic ultrasound and/or pelvic sonohystogram, cervical cytology, sexually transmitted infection testing, thyroid function studies, pregnancy test, complete blood count (CBC), ferritin measurement, liver function or coagulation studies, measurement of follicle-stimulating hormone (FSH) and luteinizing hormone (LD), hysteroscopy, dilation and curettage (D&C).

General Considerations

There are many types of abnormal uterine bleeding. This chapter focuses on menorrhagia (regular/normal intervals with excessive flow and duration). Other patterns of abnormal bleeding are oligomenorrhea (interval greater than 35 days), polymenorrhea (interval less than 21 days), metrorrhagia (irregular/frequent intervals with excessive flow and duration), menometrorrhagia (prolonged heavy bleeding at irregular intervals), and intermenstrual bleeding (variable amounts occurring between regular menses).

The normal menstrual cycle is defined as 28 days (±7 days) in length and 4 days (±4 days) in duration, with a blood loss of 40 mL (±20 mL).

The complaint of menorrhagia is largely subjective, because an objective measurement of blood loss is rarely made. Furthermore, there is a poor correlation between measured blood loss and a patient’s assessment of her bleeding (discussed in more detail later). Studies that have measured blood loss have demonstrated that patients with menorrhagia have a considerable increase in menstrual blood flow during the first 3 days (up to 92% of their total menses being lost at this time). This finding suggests that the mechanisms responsible for cessation of menstruation are as effective in women who have menorrhagia as in normal women despite the very high blood loss.

Etiology

As with any disease, proper determination of the cause is essential for effective treatment. The appropriate methodology for ruling out pathologic causes is beyond the scope of this chapter and can be found in any good text on gynecology (Table 189-1).¹ It is important to be aware of the scope of causes so that one does not just assume that the problem is “dysfunctional uterine bleeding” (DUB)—defined as abnormal uterine bleeding without any demonstrable organic cause. Abnormal bleeding can include menorrhagia, oligomenenorrhea, polymenorrhea, metrorrhagia, menometrorrhagia, and intermenstrual bleeding. Abnormal bleeding is best understood by thinking in categories of abnormalities: hormonal, mechanical, and clotting. Hormonal causes include anovulation and luteal phase defects and stress, exogenous hormones, hypothyroidism, and ovarian cysts. Mechanical causes include uterine polyps, uterine fibroids, endometrial hyperplasia, uterine cancer, intrauterine devices (IUDs), atopic pregnancy, pregnancy, endometriosis, and endometritis. Clotting abnormalities include vitamin K deficiency, drug-induced hemorrhage (heparin, warfarin, aspirin), dysproteinemias, disseminated intravascular coagulation, severe hepatic disease, primary fibrinolysis, and circulating inhibitors of coagulation; not all of these will cause menorrhagia; rather, they give rise to other abnormal bleeding patterns.

TABLE 189-1 Pathologic Causes of Menorrhagia

CAUSE	POSSIBLE ETIOLOGY
Anovulation	Excessive estrogen
	Failure of midcycle surge of luteinizing hormone
	Hypothyroidism
	Hyperprolactinemia
	Polycystic ovary disease
Intrauterine structural defects	Fibroids
	Polyps
	Cancer
	Ectopic pregnancy
	Intrauterine devices
Bleeding disorders	See Table 189-2

Data from Federman DD. Ovary. In Dale DC, Federman DD. Scientific American medicine. New York: Scientific American, 1997, 3:III:9-3:III:10.

Abnormalities in Prostaglandin Metabolism

The etiology of functional menorrhagia is currently believed to involve abnormalities in the biochemical processes of the endometrium that control the supply of arachidonic acid for prostaglandin synthesis.^2,³ Menorrhagic endometrium incorporates arachidonic acid into neutral lipids to a much greater extent than normal, whereas its incorporation into phospholipids is lower. The greater arachidonic acid release during menstruation results in the higher production of series 2 prostaglandins, which are thought to be the major factor both in the excessive bleeding seen at menstruation and in the symptoms of dysmenorrhea. The excessive bleeding during the first 3 days appears to be due to the vasodilatory properties of prostaglandins (PGs) E₂ and PGI₂ and the antiaggregating activity of PGI₂, whereas the pain of dysmenorrhea is due to the overproduction of PGF_2a.

Thyroid Abnormalities

The association of overt hypothyroidism or hyperthyroidism with menstrual disturbances is well known. However, even minimal thyroid dysfunction, particularly minimal subclinical insufficiency as determined by testing the thyroid stimulating hormone (TSH), may be responsible for menorrhagia and other menstrual disturbances.⁴ Patients with minimal thyroid insufficiency and menorrhagia have shown dramatic responses to thyroxine.⁴ It has been recommended that patients with long-standing menstrual dysfunction (who have no obvious uterine disease) should be considered for TSH testing. This approach is preferable to the empiric use of thyroid hormone.

Estimating Menstrual Blood Loss

Physicians often believe that they can assess menstrual blood loss by asking the patient to estimate the number of pads or tampons used during each period and the duration of the period. However, studies have demonstrated that there is no correlation between measured blood loss and these assessments.^1,^5,⁶ A woman’s assessment of her blood loss is extremely subjective, as demonstrated by one study finding that 40% of women with a menstrual blood loss exceeding 80 mL considered their periods only moderately heavy or scanty, whereas 14% of those with a measured loss of less than 20 mL judged their periods to be heavy.⁶

Serum ferritin levels may be the best indicator of excessive menstrual blood loss, but their determination may not be practical in terms of immediate need to know. Despite inaccuracies of patient reporting, it is important for the clinician to make an attempt at understanding blood loss. Excessive blood loss should be a concern if a woman is bleeding longer than 7 straight days or more frequently than every 21 days and is changing a pad or tampon every hour for more than half a day. Women who are changing a pad and/or tampon every half hour or even more often require urgent, perhaps emergency attention. Symptoms of light-headedness, dizziness, fainting, or the like are cause for immediate concern. Any amount of bleeding in a postmenopausal woman is considered abnormal.

Therapeutic Considerations

Many women have been subjected to needless hysterectomies because of inadequate medical management of their heavy bleeding cycles. This practice was more common over 20 years ago, but it is still followed in varying and disturbing fashion in different parts of the country. Clearly, the standard of care in conventional medicine is not the same everywhere. The time for a hysterectomy should be determined by the inability to manage menorrhagia adequately with nonsurgical interventions, patient safety and health, lack of a clear diagnosis, and the stress and fatigue wearing on the patient so that she expresses a preference for the procedure. Although we recognize the need for hysterectomy in select circumstances, most cases of menorrhagia can be treated with nonsurgical therapies, including botanicals, nutritional interventions, and hormonal and pharmaceutical therapies. Less permanent surgical procedures than hysterectomy now spare the uterus—D&C, hysteroscopic resections and ablations, and uterine artery embolization.

Psychological Considerations

Stress affects bleeding patterns directly by influencing the hypothalamic/pituitary/ovarian axis. This influence causes anovulation and the subsequent lack of progesterone production. As a result, the endometrium is in an estrogen-dominant state and becomes thickened and plump without the opposing and stabilizing effect of progesterone. This state can then lead to heavy bleeding at the next menstrual cycle. Adolescents account for many of these cases, and the remainder are often perimenopausal women.

Nutrition

Iron Deficiency

A menstrual blood loss exceeding 60 mL per period is associated with negative iron balance in most cases.⁷ Although menstrual blood loss is well recognized as a major cause of iron-deficiency anemia in fertile women, it is not as well known that chronic iron deficiency can be a cause of menorrhagia. Taymor et al ⁸ have made such a suggestion on the basis of several observations:

• Response to iron supplementation alone in 74 of 83 patients (in whom organic disease had been excluded)

• High rate of organic disease (fibroids, polyps, adenomyosis, etc.) in the patients with no response to iron supplementation

• Associated rise in serum iron levels in 44 of 57 patients

• Decreased response to iron therapy when initial serum iron levels were high

• Correlation of menorrhagia with depleted tissue iron stores (bone marrow) irrespective of serum iron level

• A significant double-blind placebo-controlled study displaying improvement in 75% of those given iron supplementation compared with 32.5% of those given the placebo

Hematologic screening and serum ferritin determination (the first parameter to indicate decreased iron levels) should be performed for patients complaining of menorrhagia. In one study, women who were menorrhagic (according to subjective information) displayed significantly lower serum ferritin levels than controls, but hemoglobin concentration, mean corpuscular volume, and mean corpuscular hemoglobin were not significantly different between the two groups.⁹ (The investigators in this study erroneously stated that such women do not require prophylactic iron supplementation since no hematologic abnormalities appeared despite significantly reduced iron stores.)

Iron supplementation, at a daily dose of 100 mg of elemental iron, has been recommended as a prophylactic therapy by several researchers because chronic iron deficiency appears to promote menorrhagia, and iron-containing enzymes are depleted before hematologic changes are observed. A decreased serum ferritin level is a good indication of the need for iron supplementation.

Vitamin A

In one study, serum retinol levels were found to be significantly lower in women with menorrhagia than in healthy controls. In this study, vitamin A was used as a treatment in 40 women diagnosed as having menorrhagia due to a number of different causes. In the group who received 60,000 IU of vitamin A for 35 days, menstruation returned to normal in 23 patients (57.5%) and was reduced in 14 (35%). Overall, the vitamin A was ineffective in only 3 of the 40 women (7.5%), and 92.5% of the 37 women had either complete relief or significant improvement.¹⁰ Although potentially effective, this therapy should not be used in women at risk of pregnancy.

Vitamin C and Bioflavonoids

Capillary fragility is believed to play a role in many cases of menorrhagia. Supplementation with vitamin C (200 mg three times daily) and bioflavonoids (dose not specified) was shown to reduce menorrhagia in 14 of 16 patients.¹¹ One of the patients with no response had endometriosis and the other had metrorrhagia. Bioflavonoids, like vitamin C, can help strengthen the walls of capillaries. Bioflavonoids may also reduce heavy bleeding through their antiinflammatory effect. A natural antiinflammatory such as a bioflavonoid may be used to reduce heavy bleeding, just as conventional medicine uses nonsteroidal antiinflammatory agents.

Because vitamin C is known to significantly increase iron absorption, its therapeutic effect could also be due to enhanced iron absorption.

Vitamin E

One group of investigators has suggested that free radicals have a causative role in endometrial bleeding, particularly in the presence of an intrauterine device.¹² Vitamin E supplementation (100 IU every 2 days) resulted in improvement in all patients by the end of 10 weeks.¹³ Although vitamin E may have produced its effects via its antioxidant activity, it is equally plausible that the vitamin affected prostaglandin metabolism in a manner that reduced bleeding.

Vitamin K and Chlorophyll

Although bleeding time and prothrombin levels in women with menorrhagia are typically normal, the use of vitamin K (historically in the form of crude preparations of chlorophyll) has clinical and limited research support.^14,¹⁵ Also, some women are found to have an inherited or acquired bleeding disorder. Table 189-2 lists some causes of acquired hemorrhagic disorders.

TABLE 189-2 Acquired Generalized Hemorrhagic Disorders

FACTOR	POSSIBLE CAUSE
Deficiency of vitamin K	Low intake, impaired absorption, antimicrobial inhibition of gut flora that synthesize vitamin K
Drug-induced hemorrhage	Heparin, warfarin
Dysproteinemias	Myeloma, macroglobinemia
Disseminated intravascular coagulation
Severe hepatic disease
Circulating inhibitors of coagulation
Primary fibrinolysis

Data from Gubner R, Ungerleider HE. Vitamin K therapy in menorrhagia. South Med J 1944;37:556-558.

Essential Fatty Acids

Menorrhagia is associated with the increased availability of arachidonic acid in the uterus.¹⁶ It now appears that the majority of tissue arachidonic acid is derived from the diet. It is therefore possible that by reducing the intake of animal products and/or increasing the intake of linoleic, linolenic, and dihomo-gamma-linolenic acid, blood loss could be curtailed by decreasing the availability of arachidonic acid. Consuming larger proportions of fish, nuts, and seeds can have an effect over time in altering the production of arachidonic acid. The use of fish oils, flax oil, and other seed oils as supplements may produce this favorable effect more quickly.