almostadoctor app banner for android and iOSalmostadoctor iPhone, iPad and android appsalmostadoctor iOS appalmostadoctor android app

Introduction

Menorrhagia describes abnormally heavy bleeding (often associated with increased period pain) during periods.

It is a common presenting compliant, and a cause is not always found. Endometrial carcinoma would always be considered as a differential.

In a typical period, the average blood loss is 30-40ml. Bleeding usually lasts 7 days or less, and a ‘normal’ cycle length is 21-35 days. Up to 30% of women report having “heavy” periods, however only about 5% of women will consult their GP for the problem.

Menstrual disorders are the second most common reason for gynaecology referral.

Epidemiology

  • 30% of women report heavy periods
    • When measuring menstrual loss, and using a cut-off of 80mls per menses, the prevalence of menorrhagia is between 10-15%
  • About 50% of cases then present medically have no cause identified – and as such are diagnosed as Dysfunctional Uterine Bleeding (DUB) – a diagnosis of exclusion

Causes of heavy menstrual bleeding

  • Ovulatory Dysfunctional Uterine Bleeding (DUB)
    • Anovulatory DUB – is more rare and occurs at the extremes of child-bearing age
  • Fibroids
  • Complications of hormonal therapy
  • Adenomyosis
  • Endometriosis
  • PCOS
  • Rare, but serious
    • Pregnancy, including its complications (e.g. miscarriage, abortion, ectopic)
    • Cancer – cervical, endometrial, ovarian, leukaemia
    • Endometrial polyps / endometrial hyperplasia
    • PID / STI
  • Other rare things
    • Pelvic congestion syndrome
    • SLE
    • Thyroid disorders
    • Bleeding disorders
    • Liver disease
  • Drugs
  • There is an association with anxiety and depression and heavy menstrual bleeding – which is probably more likely related to a perceptual problem
  • SMOKING – 5x more likely to have abnormal menstruation

Red Flags

  • Heavy bleeding with haemodynamic instability (an emergency!)
  • Postmenopausal
  • During pregnancy
  • Pelvic mass
  • Findings on USS
    • Endometrium >12mm thick in pre-menopausal women
    • Endometrium >5mm thick in peri-menopausal women

History

  • Menarche
    • Have periods always been heavy? (consider bleeding disorder)
  • Menstrual history
    • What is the normal pattern?
    • When did the heavy bleeding start?
    • What sanitary products does she use and how often are they changed?
    • Note there is no direct correlation between length of period and total blood loss
  • Could she be pregnant?
  • Cervical screening history
  • Effect of symptoms on every day life
    • Is she having regular time off work?
  • Any hirsutism (PCOS signs or symptoms)
  • Sexual history
  • Trauma
  • PMHx
    • Bleeding disorder
    • Thyroid disorder
  • FHx
  • Cancer
  • Hormonal therapy – e.g. contraceptive pill, IUD

Definition

Defining heavy bleed can be difficult. A “normal” cycle has bleeding that lasts 7 days or less, with a cycle length of between 21 and 35 days.

Consider that heavy bleeding is present if:

  • >80ml per cycle (hard to determine!)
  • If tampons / pads / cups need to be changed around every hour
  • Having to use two sanitary products in combination
  • Passing large clots. Clots often cause pain as they pass through the cervix
  • If bleeding lasts >1 week

Examination

  • If very heavy and acute bleeding – ensure haemodynaically stable
    • HR
    • BP
  • Abdominal / pelvic examination
    • Feel for masses – particularly pelvic masses
  • Consider speculum examination +/- pap smear +/- swabs for STI if indicated
    • Consider if appropriate in young girls with no sexual history as can be a traumatic experience

Investigations

  • Bloods
    • FBC
    • Iron studies
    • Coags – INR / PT / APTT / fibrinogen / platelets
    • B-hCG
    • TFTs
    • Autoantibodies – e.g. ANA for SLE
    • Consider hormones  – LH, FSH, estradiol, prolactin
  • Consider pelvic / transvaginal USS
    • Ideally should be reserved for women who fail conservative management, or are at high risk of endometrial cancer
    • Perform in first half of cycle when endometrial thickness can be measured
      • >12mm in premenopausal or >5mmin post menopausal women requires endometrial biopsy

Management

Acute:

  • If haemodynamically unstable – refer to emergency department
  • If haemodynamically stable but Hb <80 – refer for urgent gynaecology assessment (also consider going via emergency)
  • To stop acute bleeding, choose one of the following
    • Tranexamic acid 1g to 1.5g PO every 8 hours – until bleeding ceased
    • Progesterones:
      • Norethisterone 5-10mg PO every 4 hours until bleeding stops
      • Medroxyprogesterone 10mg PO every 4 hours until bleeding stops
  • Consider urgent USS

Non-acute:

  • Consider prompt USS
  • Treat any iron deficiency
  • If USS is normal, age <35 and no red flags, can treat in the community. Choose one of the following options:
    • Intra-uterine device (e.g. Mirena)
      • Recommended first line in the UK
      • Studies show women reported a greater improvement in quality of life with mirena compared to other treatments
      • However – has a high rate of removal – about 30% by 2 years
    • Combined hormonal contraceptive (provided no contra-indications). May choose to run packets together to avoid periods altogether – this is safe to do for up to 12 months at a time
    • Tranexamic acid 500mg PO BD or TDS for 2-3 days with periods
    • NSAIDs
      • Ibuprofen 400mg TDS
      • Naproxen 500mg stat dose, and then 250mg TDS
      • Mefanamic acid 500mg TDS
    • Progestins are considered third line, after IUS, CHC / NSAIDs / tranexamic acid
      • Norethisterone – note this is not contraceptive. Start at 5mg TDS. Usually short term use (1-2 months only)
      • Depo-provera injection
        • Suppresses ovulation
        • Beware of reduced bone density and weight gain
        • Repeat every 12 week
    • Endometrial ablation
    • Hysterectomy may be considered as a last resort in women who are certain they do not want any (more) children
  • If no cause is identified, no red flags, and patient is aged <35, and symptoms respond to treatment – you can make a diagnosis of dysfunctional uterine bleeding (DUB)
  • If any red flags, or USS abnormalities, or age >35, refer to gynaecology. USS abnormalities include:
    • Thickened endometrium
      • >12mm in pre-menopausal women
      • >5mm in pro-menopausal women
    • Fibroids – especially if >10cm
    • Endometrial polyps

 

References

Read more about our sources

Related Articles