Menorrhagia

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Chapter 189 Menorrhagia

image 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 PGF2a.

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.

image 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.

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