Introduction

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

Menorrhagia is a common presenting compliant, and a cause is not always found. Endometrial carcinoma should 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.

• It is no longer typically recommended to try to estimate the amount of blood loss – instead it is enough to make a diagnosis of menorrhagia on the basis of the women’s perception of a large amount of bleeding, and the impact on her life.

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)
  • This essentially refers to a type of menorrhagia where no underlying cause is identified
  • Anovulatory DUB – is more rare and occurs at the extremes of child-bearing age
• Fibroids
• Complications of hormonal therapy
  • Combined hormonal contraceptive pill
  • IUD
• 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 a 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
  • Endometrial cancer
  • Bowel cancer
• 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
• The woman perceives that she has heavy bleeding

Examination

• If very heavy and acute bleeding – ensure haemodynaically stable
  • HR
  • BP
• Abdominal / pelvic examination (bimanual 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 department)
• 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

Flashcard

References

• Menorrhagia – patient.info
• Menorrhagia – HealthPathways
• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.

Read more about our sources

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