> Table of Contents > Menorrhagia (Heavy Menstrual Bleeding)
Menorrhagia (Heavy Menstrual Bleeding)
Brian D. Bates, MD
Joanne Wilkinson, MD, MSc
image BASICS
DESCRIPTION
  • The current preferred terminology for menorrhagia is “heavy menstrual bleeding” (HMB), a subcategory of “abnormal uterine bleeding” (AUB) (1).
  • HMB is an excessive amount (≥80 mL/cycle, compared with normal average of 30 to 60 mL/cycle) or duration of menstrual flow at predictable intervals.
  • HMB applies only to ovulatory menses.
  • Other patterns of AUB which may overlap with HMB include:
    • Intermenstrual bleeding: bleeding between regular menses
    • Irregular bleeding: typically due to ovulatory dysfunction (encompassing the previously used terms metrorrhagia and oligomenorrhea)
    • Polymenorrhea: menstrual cycle length <21 days
  • System affected: reproductive
EPIDEMIOLOGY
Prevalence
  • AUB, including HMB, is thought to affect between 9% and 14% of women between menarche and menopause (2).
  • AUB is more common close to menarche and menopause.
Pediatric Considerations
  • Genital bleeding before puberty is not menstrual bleeding by definition and requires further evaluation.
  • HMB presenting in adolescence is more likely related to a bleeding disorder, and patients should be evaluated for a bleeding disorder (3).
  • Postmenarchal patients may have heavy and irregular menstrual bleeding related to an immature hypothalamic-pituitary axis.
Pregnancy Considerations
Bleeding in pregnancy is not menstrual bleeding by definition and requires further evaluation. Pregnancy test should be obtained as part of the evaluation of abnormal uterine bleeding.
Geriatric Considerations
Menopause is diagnosed after 12 months of amenorrhea in the absence of other causes and is typically preceded by irregular bleeding. All postmenopausal bleeding requires additional workup for malignancy.
ETIOLOGY AND PATHOPHYSIOLOGY
  • No cause is identified in about 1/2 of patients.
  • Bleeding disorders
    • Von Willebrand disease (present in about 13% of patients) (2)
    • ITP and other platelet disorders
    • Factor deficiencies
    • Medication side effect most commonly related to anticoagulants including warfarin
    • Renal failure leading to uremic platelet dysfunction
    • Cirrhosis leading to coagulopathy
  • Uterine fibroids, typically submucosal
  • Endometrial polyps
  • Hypothyroidism
  • Iatrogenic causes including copper IUD
  • Endometriosis
  • Adenomyosis
  • Pelvic inflammatory disease
  • Some causes more typically presenting as irregular menstrual bleeding include:
    • Polycystic ovarian syndrome (PCOS)
    • Hypothalamic-pituitary dysfunction, often postmenarchal or during menopausal transition
    • Endometrial or ovarian neoplasia
    • Some forms of hormonal birth control
    • Hyperthyroidism
    • Hyperprolactinemia
  • HMB has been associated with increased production and sensitivity to prostaglandins.
GENERAL PREVENTION
  • Combined oral contraceptives may prevent HMB, particularly when progesterone is dominant. Lower estrogen doses result in less menstrual bleeding
  • NSAIDs including ibuprofen inhibit prostaglandin production and result in decreased blood loss and pain during menses.
  • Progesterone-only contraceptives may reduce overall blood loss but often result in irregular bleeding.
COMMONLY ASSOCIATED CONDITIONS
Iron deficiency anemia
image DIAGNOSIS
PHYSICAL EXAM
  • Prompt assessment for signs of hemodynamic instability (5)
  • Thyroid nodule or goiter suggests thyroid disease.
  • Signs of a bleeding disorder include petechiae and ecchymoses.
  • Pelvic examination, including speculum and bimanual examination, may reveal the following:
    • Cervical or vaginal source of bleeding
    • Pelvic or adnexal mass
    • Evidence of reproductive tract infection such as cervical motion tenderness
    • Uterine enlargement
  • Hirsutism, acne, and obesity are suggestive of PCOS.
DIFFERENTIAL DIAGNOSIS
  • Normal menses
  • Anovulatory bleeding
  • Intermenstrual bleeding
  • Complications of pregnancy
    • Spontaneous abortion
  • Other sources of bleeding:
    • Cervical
    • Vaginal
    • Gastrointestinal
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Pregnancy test
  • CBC to assess for:
    • Anemia
    • Thrombocytopenia
    • Leukocytosis may suggest infection
  • Thyroid-stimulating hormone (TSH) test
  • P.663

  • Labs to consider in select cases:
    • Coagulation panel for evaluation for bleeding disorder in adolescent or adult with history suggestive of bleeding disorder
    • Workup of anovulatory bleeding may also include prolactin, androgens, FSH, LH, and estrogen.
    • Appropriate cervical cancer screening
    • Evaluation for infection including gonorrhea and chlamydia
  • Imaging should be obtained based on clinician judgment and should begin with transvaginal ultrasonography.
  • Transabdominal ultrasonography should be performed if transvaginal approach does not provide full assessment of anatomy.
Follow-Up Tests & Special Considerations
  • Saline infusion sonohysterography recommended if ultrasound suggests intracavitary pathology and is more sensitive and specific than transvaginal ultrasound (2)[C]
  • Hysteroscopy can be performed if direct visualization is desired.
Diagnostic Procedures/Other
Endometrial biopsy to assess for malignancy and hyperplasia is recommended in some situations including (5):
  • Any AUB, including HMB, after age 45 years in an ovulatory (premenopausal) woman
  • Woman <45 years with persistent or refractory AUB, risk factors such as unopposed estrogen exposure, or concerning endometrial imaging
image TREATMENT
GENERAL MEASURES
Treat underlying conditions (e.g., hypothyroidism) when possible.
MEDICATION
First Line
  • For acute control of severe bleeding (6):
    • Obtain IV access and consider blood transfusion or clotting factor administration.
    • Estrogen, conjugated equine: 25 mg IV every 4 to 6 hours for 24 hours
    • Monophasic combined oral contraceptive that contains 35 &mgr;g ethinyl estradiol: 3 times per day for 7 days
    • Medroxyprogesterone acetate: 20 mg orally 3 times per day for 7 days
    • Tranexamic acid: 1.3 g orally or 10 mg/kg IV 3 times per day for 5 days, antifibrinolytic agent
  • For less severe bleeding (typical case) or after control of acute bleeding has been achieved (2):
    • Levonorgestrel intrauterine device (Mirena IUD): typically results in light bleeding or amenorrhea with patient satisfaction similar to hysterectomy and endometrial ablation (7)[A]
    • Combination estrogen-progestin oral contraceptive: may be prescribed in cyclic, extended, or continuous dosing and typically results in regular, lighter, and less painful menses
    • Depot medroxyprogesterone acetate: 150 mg/1mL IM every 3 months, typically results in amenorrhea or light irregular bleeding
    • Tranexamic acid: 1.3 g orally for 5 days during menses; antifibrinolytic agent that is an option for women who desire nonhormonal treatment NSAIDs (e.g., naproxen, mefenamic acid, ibuprofen) can reduce blood loss and dysmenorrheal (2)[B].
Second Line
  • Noncontraception estrogen-progestin oral contraceptives (ultra-low-dose estrogen): may be considered when a relative contraindication to estrogen is present
  • Oral progestins: multiple formulations and dosing, typically used in women who have contraindications to estrogen or are trying to conceive
SURGERY/OTHER PROCEDURES
  • Dilation and curettage can be considered in the setting of acute severe bleeding.
  • For women who desire fertility, myomectomy may be considered for treatment of uterine leiomyomas (fibroids).
    • For women who do not desire fertility, consider endometrial ablation, uterine artery embolization, or hysterectomy.
    • Endometrial ablation shows similar outcomes to levonorgestrel IUD, patients still require contraception.
    • Uterine artery embolization is used to treat uterine leiomyomas.
    • Hysterectomy is curative but with significant complications and long recovery, typically reserved for failure of medical management or presence of another indication such as malignancy.
image ONGOING CARE
DIET
Iron supplementation may help correct for increased blood loss.
PATIENT EDUCATION
Patient and provider should engage in informed decision making with understanding of treatment risks and benefits.
PROGNOSIS
Most patients respond well to medical management, and hysterectomy is a curative option in appropriate cases.
REFERENCES
1. Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113(1):3-13.
2. Sweet MG, Schmidt-Dalton TA, Weiss PM, et al. Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012;85(1):35-43.
3. Diaz A, Laufer MR, Breech LL. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics. 2006;118(5):2245-2250.
4. Matteson KA, Munro MG, Fraser IS. The structured menstrual history: developing a tool to facilitate diagnosis and aid in symptom management. Semin Reprod Med. 2011;29(5):423-435.
5. Matthews ML. Abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol Clin North Am. 2015;42(1):103-115.
6. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013;121(4):891-896.
7. Lethaby A, Hussain M, Rishworth JR, et al. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2015;(4):CD002126.
Codes
&NA;
ICD10
  • N92.0 Excessive and frequent menstruation with regular cycle
  • N92.3 Ovulation bleeding
  • N92.2 Excessive menstruation at puberty
Clinical Pearls
&NA;
  • Women with heavy menstrual bleeding are at high risk for iron deficiency anemia.
  • A thorough menstrual history is critical to differentiate heavy menstrual bleeding from similar conditions including anovulatory bleeding.
  • Teenagers presenting with heavy menstrual bleeding should be evaluated for an underlying bleeding disorder.
  • All postmenopausal bleeding and bleeding during pregnancy requires additional workup.
  • The Levonorgestrel (Mirena) intrauterine device may be used for heavy menstrual bleeding and is associated with high patient satisfaction rates.