Health Awareness blog

Menorrhagia is defined as bleeding of more than 80ml per cycle or a menstrual cycle that lasted longer than 7 days over several consecutive cycles. However, in clinical practice, where actual measurement is not possible, management deals with those women whose significant menstrual loss interferes with their normal life.

During normal menses, the amount of blood loss is an average of 40 + 20 ml over a period of between 2 and 6 days in cycles of 21 to 35 days. In reality, menorrhagia is suggested by the presence of clots, flooding (gushing flow that soaks pads and undergarments), increased duration of bleeding and number of pads used per day.

The initial diagnosis is often based on subjective evaluation of blood loss.

  CAUSES   The most likely cause changes with age. Benign pathology is generally more common in younger women and those with regular cycles. The chances of malignancy are very low in these groups. For example, pregnancy and dysfunctional uterine bleeding is more common seen in girls. Causes of menorrhagia also can be divided using following categories. 

• Gynaecological (e.g., fibroids, polyps, adenomyosis, cancer)
• Medical (i.e., bleeding disorders. Systemic bleeding disorders account for 7 – 20 percent of women of all ages who present with menorrhagia. This should be considered in all adolescents with early onset menorrhagia.)
• Drugs like heparin and warfarin
• Intrauterine devices
• Dysfunctional uterine bleeding (DUB) – is diagnosed when no obvious cause can be established. It is associated with anovulatory cycles, so DUB is common at the extremes of reproductive life. This is the diagnosis by exclusion.

   TESTS   None may be needed. But sometimes, we need to run some investigations that will help with the diagnosis and management. 

• Full blood count – look for haemoglobin. Patient with low haemoglobin content will need blood transfusion.
• Thyroid function test – menorrhagia can be present in hypothyroidism
• Ultrasound or laparoscopy – if we suspect of pelvic pathology
• Dilatation and curettage – usually done in perimenopausal women to rule out endometrial cancer

   TREATMENT  

Treat the underlying cause is the mainstay of treatment. However, if the bleeding is mild or recent onset – just observe. No need for any medical intervention yet. In dysfunctional uterine bleeding, the treatment will depend on age and the wish of the patients. Reassurance will help.

  Those with unacceptable loss should be offered treatment: 

• Hematinics to combat anemia
• Weight reduction in obese patients as excess weigh increased the risk of irregular menses
• Tranexamic acid 1gm thrice daily or 4 times daily over 3 to 5 days.
• NSAIDs (e.g., mefenamic acid 500mg thrice daily for 3-5 days)
• Oral contraceptives (containing 30mcg estrogen) either monthly or a tricyclic regimen (taking active pills continuously for 3 cycles before taking a week break). For maximum effectiveness, tranexamic or NSAIDs should be started at the first sign of menstruation.

  Other treatments if first line agents fail: 

• Progestogen (oral or indictable, implants)
• Mirena
• Danazol
• Gonadotrophin-releasing hormone agonist

  If medical treatment fails, surgery is the next option: 

• Operative hysteroscopy – least invasive method. Involve the insertion of a loop via the vagina to remove any fibroids, polyps or the endometrium.
• Endometrial ablation is the current option used to destroy thickened endometrial lining.
• Hysterectomy – this is the last resort or if the patient presented with other pelvic pathology

Reference:

1. Overview of gynaecology in primary care, medical tribune 1-15 march 2008, page 20-21.
2. Oxford handbook of clinical specialties, 5^th edition.

Tags: causes, diagnosis, Medical, menstrual, surgery, treatment, woman

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