Menorrhagia

Signs and symptoms

Usually in a menstrual period 25 and 80 mL of total blood flow is normal, on average soaking a pad or tampon every few hours or less. On average the menstrual cycle is 21 – 35 days and the bleeding period is for 5 – 7 days. Menorrhagia can be in terms of how often a woman gets her period or the length of the bleeding period or the volume of blood loss. Sign and symptoms are associated with its complications such as anaemia. This can lead to fatigue and shortness of breath.

Causes

There is not always a cause of menorrhagia and it can be considered idiopathic. However, some causes can lead to heavy uterine bleeding:

• Dysfunctional uterine bleeding is a condition where there is abnormal heavy bleeding from the vagina due to hormone levels with the absence of pelvic pathology.
• Painless excessive menses can be due to fibroids, adenomyosis, coagulation problems, endometrial cancer, and endometrial polyp.
• Fibroid: also known as a leiomyoma is in the uterus and is a benign smooth muscle tumour. There is usually a family history of fibroids and can be linked with obesity and eating red meat.
• Adenomyosis: It is the presence of endometrial glands and stromal cells deep within the myometrium which causes proliferation of smooth muscles
• Coagulation problems: Normal coagulation limits the amount of bleeding during a period. There can be problems with platelets such as immune thrombocytopenia (low platelet count). Problems with coagulating factors such as von Willebrand disease, haemophilia a and b, or drug induced by anticoagulant such as warfarin use.
• Endometrial polyp: This is a mass in the uterus lining that can be pedunculated or sessile. Small blood vessels of the polyp can bleed and increase blood loss and lead to menorrhagia.
• Endometrial cancer: This is cancer that of the endometrium in the lining of the uterus. If a patient is postmenopausal and experiences uterine bleeding, this is the first differential that needs to be ruled out.
• Painful menorrhagia could be caused by endometriosis and pelvic inflammatory disease.
• Endometriosis: There is a growth of endometrial tissue outside of the uterine cavity.
• Pelvic inflammatory disease: There are several different infections like chlamydia which can cause heavy bleeding. Other possible causes and conditions to think about are an intrauterine contraceptive device, hypothyroidism, or excessive stress.

Investigations

It is important to investigate all possible underlying causes of menorrhagia firstly performing a physical examination including a pelvic examination to confirm where the bleeding is coming from. For women of childbearing age, a urine pregnancy test is essential to check. Blood tests checking for a full blood count are necessary to identify signs of anaemia, prolactin, liver function tests and thyroid function tests to check for hypothyroidism. Coagulation studies such as Prothrombin time (PT) and activated partial thromboplastin time (aPTT) and specific test for von Willebrand disease need to be carried out. Hormone levels need to be analysed in addition to testing for serum free testosterone is indicated in signs of excessive androgen for women with hirsutism or acne. Other investigations to consider are a Pap smear to check for of cervical abnormalities. Imaging of the uterus with a pelvic ultrasound scan will rule out the possibility of structural abnormalities such as fibroids or polyps.

To investigate for endometrial cancer, an endometrial biopsy can be performed. Hysteroscopy can be useful to visualise the uterine cavity with an endoscopy and is indicated in cases where polyps, fibroids, or endometrial cancer is suspected.

Management

The underlying cause once identified needs to be managed accordingly. However, menorrhagia may resolve spontaneously. It is essential to assess if the patient is haemodynamically stable, intravenous fluids may be necessary to stabilize. If anaemia is present, then iron replacement therapy can be started. First line treatment is an intrauterine device with progesterone such as the Mirena, which is effective for up to five years. The second line is to use the combined oral contraceptive pill or medications like Tranexamic acid or non-steroidal anti-inflammatory drugs can help prevent blood loss.

For third line management progesterone only pill can help reduce heavy bleeding in some women. Depo Provera is injectable progesterone that is a longer-term treatment option. Other options are to use a gonadotropin releasing hormone agonist.

The surgical option for removing the cause of bleeding like fibroids, endometrial polyps,intrauterine adhesions and lost IUCD by hysteroscopy is a definitive treatment. Other surgical options include Dilation & Curettage (D&C), endometrial ablation, uterine artery embolization, myomectomy, and hysterectomy can be performed.

Complications

The main complication of menorrhagia is iron deficiency anaemia. The symptoms can be resolved by iron replacement therapy.