Menorrhagia Disease

BASICS

DESCRIPTION

Excessive amount or duration of menstrual flow, at more or less regular intervals

Distinguish from, but may overlap with:
- Metrorrhagia - irregular or frequent flow, noncyclic
- Menometrorrhagia - frequent, excessive, irregular flow (menorrhagia plus metrorrhagia)
- Polymenorrhea - frequent flow, cycles of 21 days or less
- Intermenstrual bleeding - bleeding between regular menses
- Dysfunctional uterine bleeding (DUB) - abnormal endometrial bleeding of hormonal cause and related to anovulation
System(s) affected: Reproductive
Genetics: N/A
Incidence/Prevalence in USA: Abnormal bleeding is common; prevalence varies with definition (endometrial carcinoma: about 40,000 new cases per year)
Predominant age:
- Menarche to menopause; about 50% of cases occur after 40 years of age
- Dysfunctional bleeding is fairly common in adolescence and near menopause
Predominant sex: Female only

SIGNS AND SYMPTOMS

"Excessive" menstrual flow defined subjectively varies greatly from woman to woman (average normal menstrual flow is about 30-40 mL per cycle)
Useful historical features include:
- Bleeding substantially heavier than the patient's usual flow
- Bleeding lasting more than 7 days
- Flow associated with passage of significant clots
- Anemia
The following symptoms tend to suggest that cycles are ovulatory:
- Regular menstrual interval
- Mid-cycle pain (mittelschmerz)
- Dysmenorrhea
- Premenstrual symptoms - breast soreness, mood changes, etc.
Abdominal pain or cramps at other times of the cycle may be associated with structural causes:
- Myomas
- Polyps
- Ovarian tumors
Hirsutism or acne
- May accompany polycystic ovarian syndrome

CAUSES

Hypothyroidism
Endometrial proliferation/excess/hyperplasia:
- Anovulation, oligo-ovulation
- Polycystic ovarian disease (PCOD)
- Ovarian tumor
- Obesity
- Hormone (estrogen) therapy
Endometrial atrophy:
- Postmenopause
- Prolonged progestin or oral contraceptive administration
Local factors:
- Endometrial polyps
- Endometrial neoplasia
- Adenomyosis/endometriosis
- Uterine myomata (fibroids)
- Intrauterine device (IUD)
- Uterine sarcoma
Coagulation disorders:
- Thrombocytopenia, platelet disorders
- von Willebrand's disease
- Leukemia
- Ingestion of aspirin or anticoagulants
- Renal failure/dialysis

RISK FACTORS

Obesity
Anovulation
Estrogen administration (without progestin)
Prior treatment with progestational agents or oral contraceptives increases the risk of endometrial atrophy, but decreases the risk of endometrial hyperplasia or neoplasia

DIAGNOSIS

LABORATORY

Pregnancy test
CBC to assess severity of blood loss, exclude thrombocytopenia and leukemia
In selected cases:
- TSH - elevated in hypothyroidism
- Platelet count, bleeding time, prothrombin time (PT), partial thromboplastin time (PTT) for coagulation screen
- Creatinine, BUN
- 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

Drugs that may alter lab results: Progestins used prior to endometrial biopsy may cause decidualization and obscure true diagnosis
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Vary with cause: see Causes

SPECIAL TESTS

Endometrial biopsy detects hyperplasia, dysplasia, or atrophy. If done prior to expected menses, may also help make the diagnosis of anovulation or luteal phase defect.

IMAGING

Ultrasonography to evaluate adnexal masses or fibroids suspected from pelvic exam
Transvaginal ultrasonography to measure thickness of endometrium may help distinguish bleeding due to atrophy from bleeding due to hyperplasia
Computerized tomography used in investigation of potentially malignant pelvic masses

DIAGNOSTIC PROCEDURES

Pelvic and rectal examination
Pap smear
Endometrial biopsy
Diagnostic dilatation and curettage
Hysteroscopy

TREATMENT

APPROPRIATE HEALTH CARE

Most cases can be managed as outpatients in office or emergency department
Hospitalize for bleeding accompanied by orthostatic hypotension or hematocrit < 25%

GENERAL MEASURES

Rule out pregnancy complications and non-uterine bleeding
Treat severe or life-threatening bleeding acutely:
- Intravenous estrogen
- Curettage if necessary
- Hysterectomy in extreme case
Proceed to identify underlying cause of bleeding and treat to prevent recurrence
- Hormonal therapy
- Dilatation and curettage for hormone-unresponsive cases
- Consider endometrial ablation or hysterectomy in persistent cases where fertility is not desired
- Specific treatment for neoplasia, polyps, systemic disease, etc.
- Patients who desire fertility may also need appropriate treatment for anovulation, endometriosis, myomata, etc.

SURGICAL MEASURES

See general Measures

ACTIVITY

As tolerated. Resting with feet elevated may be helpful.

DIET

Iron supplementation may help correct for increased blood loss

PATIENT EDUCATION

Information about side effects of medications

FOLLOW UP

PREVENTION/AVOIDANCE

Pap smear and pelvic examination annually

POSSIBLE COMPLICATIONS

Anemia

EXPECTED COURSE AND PROGNOSIS

Varies with cause of bleeding
Most patients with hormonal causes will respond to hormonal manipulation

MISCELLANEOUS

ASSOCIATED CONDITIONS

Metrorrhagia; menometrorrhagia; androgenic disorders

AGE-RELATED FACTORS

Pediatric: Genital bleeding prior to puberty can result from trauma, foreign bodies, vaginal infection, or exogenous hormone administration
Geriatric: Genital atrophy may predispose to bleeding with minimal trauma. Neoplasm of ovary or endometrium must be ruled out.
Others:

In adolescence, irregular bleeding due to anovulation and immaturity of the hypothalamic-pituitary-ovarian axis is common
Beyond age 35-40, endometrial dysplasia and endometrial carcinoma are significant causes of bleeding. Obtain endometrial sampling before attempting hormonal treatment.

PREGNANCY

Bleeding in pregnancy is not menorrhagia. Complications of pregnancy or cervical/vaginal lesions should be considered.

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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