Annually, 2 million women in the United States consult a health-care provider for treatment of heavy menstrual bleeding. Though only a fraction of these women will be found to have clinically significant menorrhagia, each deserves a thorough history and physical examination, and some will require laboratory and other diagnostics.
Menorrhagia is not a diagnosis per se but a symptom indicative of one or more underlying conditions. While the range of differential diagnoses for menorrhagia includes such disparate conditions as uterine fibroids, renal disease, bleeding disorders, and menopause, a common-sense approach focused on age, associated symptoms, and risk factors can lead to the appropriate diagnosis and treatment. Through a careful basic workup, primary-care clinicians can provide important first-line assessment and treatment and make referrals as needed.
What is menorrhagia?
The classic definition of menorrhagia is menstrual bleeding >80 mL in total volume occurring at regular intervals or prolonged bleeding lasting longer than seven days. “Regular” menstrual cycles occur at a predictable interval (anywhere between 21 and 35 days). In most instances, women lose 30-35 mL of blood each cycle, the equivalent of approximately eight soaked pads or tampons, and experience two to six days of bleeding per cycle.1
While these precise definitions may be useful in a research setting, practicing clinicians must rely on patients' subjective assessments to make a diagnosis. Gynecologic surveys find that 30% of all premenopausal women describe their own bleeding as excessive. In research studies, however, fewer than half of these women actually lose >80 mL of blood with their menses.2
Diagnosis
The cyclic nature of menorrhagia distinguishes it from other forms of abnormal uterine bleeding. Understanding the distinctions between the various disorders of the menstrual cycle is crucial in making an accurate diagnosis (Table 1) and determining the proper course of evaluation and treatment. In taking a menstrual history, ask not only about the quantity of blood loss but also the pattern, frequency, and duration of the bleeding. For example, heavy menstrual bleeding occurring at regular, monthly intervals would be classified as menorrhagia, while episodes of bleeding—whether heavy, moderate, or light—occurring more than 35 days apart would be best classified as oligomenorrhea. While these disorders may share some differential diagnoses, they should be considered as separate phenomena and each must receive a proper workup.
Various assessment tools can aid in quantifying your patient's bleeding and determining the applicability of the menorrhagia label. A simple menstrual diary can enable patients to document the amount and pattern of their bleeding. Instructing patients to record all vaginal bleeding for a few weeks to months can help establish whether a regular pattern exists and determine the appropriate set of differential diagnoses. Patients should track the timing of pad or tampon changes, the type of pads or tampons used, and how much blood the pad or tampon contains each time. Adolescent patients in particular may require education and reassurance about the normal menstrual cycle and appropriate use of hygiene products.
Pictorial depictions of pads and tampons are available to assist the patient in her documentation.3,4 It is also useful to know that the typical maxi pad can hold 5-15 mL of blood; the typical tampon can hold 5 mL. Passing clots larger than 1 inch in diameter and changing a saturated pad or tampon more than once an hour are predictive of clinical menorrhagia.5
Another cornerstone of the subjective menorrhagia assessment is health-related quality of life, which has been noted to be significantly lower in women with menorrhagia and can serve as a marker of improvement after treatment.6 If the patient's menstrual flow is sufficient to compromise her quality of life—whether by frequency of pad changes, dysmenorrhea, or fatigue or other symptoms of anemia—the symptom warrants immediate investigation and intervention.
Subjective assessment
A careful history can successfully and accurately steer the diagnostic process. Focus on the duration and severity of the bleeding as well as associated symptoms, such as pain or cramping. Duration may be especially helpful in narrowing the differential diagnoses. Menorrhagia that has been present since menarche suggests a bleeding disorder, while menorrhagia with onset after age 40 is more likely an anatomic lesion or perimenopause. The most frequent cause of sudden-onset acute menorrhagia is an accident or complication of pregnancy.
Investigation of the patient's medical and family history should focus on likely causes of menorrhagia: coagulopathies, thyroid disease, endometrial or uterine cancers, fibroids, and liver or renal disease. It may be helpful to ask whether the patient's mother or any sisters had a hysterectomy prior to menopause. Currently 20%-30% of hysterectomies are performed for a chief complaint of menorrhagia, and this number may have been higher in the past.
A careful medication inventory may reveal an iatrogenic cause of menorrhagia (e.g., daily aspirin or other prescription, OTC, or herbal anticoagulants). Many patients on regimens of fish oil or other OTC anti-inflammatories do not recognize the potential effects of these medicines on menstrual flow (Table 2). Steroid hormones and chemotherapy agents may also disrupt the menstrual cycle. Women who have recently stopped using injectable or oral progestins, oral contraceptives (OCs), or other hormonal birth control methods may notice a marked increase in their monthly flow. A copper IUD can also cause excessive menstrual bleeding. Some women will experience menorrhagia for up to a few months following medication abortion. These effects should be self-limiting unless another underlying cause for menorrhagia is present.
Social history should focus some attention on the patient's quality of life to determine how much the menorrhagia is interfering with her daily activities. The social history should also focus on possible risks for sexually transmitted infection (STI) exposure. Chlamydia, gonorrhea, and trichomoniasis can all cause cervicitis resulting in abnormal bleeding. In these circumstances, review of systems may also reveal postcoital bleeding, abnormal vaginal discharge, abdominal pain, or dyspareunia. Screening for abuse and trauma should be included in the social history as well.
The review of systems is among the most potentially revealing components of the menorrhagia workup. This should include signs of underlying causes of menorrhagia (e.g., bleeding disorders) and its sequelae (e.g., anemia).
Inquire about other evidence of abnormal or prolonged bleeding, such as easy bruising, gingival bleeding after tooth brushing, prolonged epistaxis, or uncontrolled bleeding with superficial cuts. Prolonged bleeding after surgery (including dental extractions) may signal a coagulopathy. Signs and symptoms of thyroid disease (e.g., heat or cold intolerance, mood changes, and weight or appetite changes) should be investigated. Even subclinical cases of hypothyroidism can produce heavy menstrual bleeding. In women who may be experiencing menopause, inquire about vasomotor symptoms, difficulty sleeping, and changes in libido. Women with an anatomic lesion (i.e., fibroids) may note dysmenorrhea, abdominal or back pain, or difficulty with bowel movements.
In severe or ongoing menorrhagia, signs and symptoms of anemia may be present. Patients should be asked about such symptoms as shortness of breath, heart palpitations, light-headedness, dizziness, fatigue, pallor, and nausea or vomiting. It is also important to ask whether the patient is using iron supplements or taking a multivitamin routinely.
Objective assessment
A full head-to-toe physical, prioritizing the assessment of hemodynamic stability, should be conducted on all women complaining of menorrhagia. Gait and affect should be observed for possible evidence of dizziness, fatigue, or shortness of breath. Vital signs, including height, weight, heart rate, BP, and temperature, if indicated, should be recorded.
Carefully examine the patient's skin for pallor and for petechiae, ecchymoses, or other evidence of a coagulopathy. Note any signs of thyroid disease and carefully palpate the thyroid gland. If you suspect liver or renal disease, assess for skin changes, organomegaly, and other clinical manifestations.
Pelvic examination should include both a speculum exam to assess the integrity of the cervix and vagina and a careful bimanual exam to check for cervical motion tenderness and uterine or adnexal masses. Depending on what the history and exam reveal, cervical cultures, cervical cytology (Pap smear), pelvic ultrasonography, or other diagnostic procedures may be indicated.
Diagnostic testing
Urine human chorionic gonadotropin is the first-line test to rule out pregnancy or spontaneous abortion. If spontaneous abortion is suspected, any collected tissue may be sent for pathologic examination.
Women with signs or symptoms of anemia, as well as those with severe or long-standing menorrhagia, should be evaluated with a hemoglobin and hematocrit determination or a complete blood count.
Coagulopathy studies are recommended for women whose menorrhagia dates back to menarche or remains idiopathic after a full workup, those who have a suspicious personal or family history, and patients undergoing hysterectomy for menorrhagia.7 Platelet count, prothrombin time, partial prothrombin time, and bleeding time are appropriate first-line studies. The most common coagulopathy is von Willebrand disease, which is present in 11%-16% of women with menorrhagia; coagulopathy screening should therefore include early testing for von Willebrand factor.8
Other serology, such as thyroid-stimulating hormone, liver function testing, blood urea nitrogen, and creatinine should be considered, depending on the patient history and exam.
Endometrial biopsy is warranted for women at high risk of endometrial hyperplasia or uterine cancer. This includes patients who have had bleeding after menopause or who used exogenous estrogen therapy without opposing progesterone, those with a history of polycystic ovary syndrome or a family history of uterine cancers, and those who are obese or older than 35 years.
Pelvic ultrasound is indicated if bimanual exam reveals abnormal uterine size or shape. Some experts also recommend pelvic ultrasound as a first-line screening for endometrial cancer; biopsy is advisable if the endometrial stripe measures >12 mm.
Ultrasound may reveal fibroids or adenomyosis. Myomas, or fibroids, are common benign uterine growths that occur in up to one third of women.9 Though many women with fibroids never experience symptoms, heavy menstrual bleeding is the most common complaint among those who do. Submucosal fibroids that distort the uterine cavity or protrude into the cavity are most likely to cause abnormal bleeding. Because fibroids are common and are frequently asymptomatic, it is important to exclude other concomitant causes of menorrhagia, even after a diagnosis of fibroids is made.
If an intracavitary growth, such as a submucosal fibroid or a uterine polyp, is suspected, saline infusion sonohysterography (SHG) should be conducted. SHG consists of infusing sterile saline fluid into the uterus while capturing a real-time image of the uterine cavity on ultrasound. Hysteroscopy with directed biopsy may be indicated if SHG and/or endometrial biopsy reveal a need for further investigation.
Treatment
Treatment approaches for menorrhagia are based on the underlying medical cause and the onset, duration, and severity of the bleeding. Even the most thorough workup may fail to reveal a specific cause of the menorrhagia, especially in perimenopausal women. In these circumstances, the patient's desire for future childbearing, relevant comorbidities, and personal preferences largely guide the choice of intervention. A recent proliferation of management options has reduced unnecessary hysterectomies, avoiding surgical risk, financial cost, and permanent loss of fertility.
When a specific cause has been identified, treating the underlying disorder should eliminate the symptom. For instance, such bleeding disorders as von Willebrand disease require treatment with agents to prevent future bleeding (e.g., desmopressin). Abnormal thyroid function can usually be medically corrected, as can cervical infections or iatrogenic menorrhagia. Fibroids can be managed operatively via hysteroscopy, laparoscopic or abdominal myomectomy, or hysterectomy, depending on the extent of the lesions and the patient's surgical risk factors and desire for future childbearing. Such surgical alternatives as uterine artery embolization are gaining in popularity. If menorrhagia persists after apparently successful treatment for the underlying condition, additional causes should be investigated.
Women experiencing acute menorrhagia will need careful assessment of their hemodynamic stability and quick intervention to regulate bleeding. High-dose oral estrogen therapy with combined OCs or an estradiol formulation remains the mainstay of acute treatment (although some patients may require hospitalization for IV medications or dilation & curettage). Once stabilized, these patients will likely require long-term preventive therapy.
Nonsteroidal anti-inflammatory agents (NSAIDs) can serve as a useful adjunct treatment for menorrhagia, helping to relieve cramping as well as inducing vasoconstriction to reduce blood flow. Treatment options include ibuprofen 200-400 mg every four to six hours, mefenamic acid 500 mg as a loading dose followed by 250 mg every six hours, and naproxen 275 mg every eight hours. Studies show that effective NSAID use can result in a reduction in menstrual bleeding of 25%-35%.
Anemia from menstrual blood loss should be corrected concurrently with treatment of menorrhagia. Dietary iron sources, multivitamins, or ferrous sulfate may be advisable, depending on the extent of the deficiency. A very small percentage of women with menorrhagia will have anemia severe enough to require transfusion.
Prevention of future bleeding episodes is often best accomplished through ongoing hormonal treatment. Combined OCs containing estrogen and progestin can help to control menorrhagia, reducing bleeding by up to 60%. Other delivery mechanisms for hormones, such as the vaginal contraceptive ring (etonogestrel/ethinyl estradiol [NuvaRing]) and the transdermal patch (norelgestromin/ethinyl estradiol [Ortho Evra]), can be used if preferred. Continuous dosing of active pills or NuvaRing to eliminate withdrawal bleeding can be especially helpful for women with a history of menorrhagia, particularly those with concomitant anemia. Women with high BP, heart disease, or other risk factors for blood clots should avoid combined OCs. Other medical contraindications (e.g., a history of breast cancer) exist and should be reviewed prior to prescribing these medications to any patient. The patch is not recommended for women who weigh more than 198 lb.
Progestins can effectively suppress the endometrium to prevent abnormal bleeding. Depot medroxyprogesterone acetate (DMPA) may be injected every three months. After one year on DMPA, 70% of women will be amenorrheic.10 Side effects include weight gain, mood changes, and hair loss. Oral progestins, such as medroxyprogesterone or norethindrone, may be given daily or for 10-14 days of a 28-day menstrual cycle.
Many studies have affirmed the use of the levonorgestrel-containing intrauterine system (LNG-IUS) for management of menorrhagia.11,12 By releasing 20 µg of progestin daily for five years, the LNG-IUS reduces overall blood loss by about 90% and induces amenorrhea or oligomenorrhea in a majority of women. Even women who have failed to respond to other medication regimens may benefit from use of the LNG-IUS. The LNG-IUS also serves as a highly effective (<1% annual failure rate) but reversible form of contraception and is currently FDA-approved for five years' use. Some studies also demonstrate a reduction in size of uterine fibroids with use of the LNG-IUS.13 Women at high risk for STI or with other medical conditions may not be candidates for an LNG-IUS.
Endometrial ablation was pioneered in the late 20th century as a highly effective alternative to hysterectomy for the treatment of menorrhagia. Loop or rollerball electrocautery, laser techniques, and thermal balloon ablation are popular alternatives and can usually be performed as outpatient surgery. While many women achieve symptom relief following ablation, up to 40% of patients will go on to require further intervention.14
The LNG-IUS has numerous advantages over endometrial ablation and hysterectomy, including relatively low cost, reversibility, and ease of application.15 The LNG-IUS may be inserted in the office by a trained health-care provider and does not require highly specialized surgical equipment or operating space. Additionally, all women who undergo hysterectomy and many who undergo ablation are unable to become pregnant following those procedures,while the LNG-IUS may preserve future fertility.
Hysterectomy remains the treatment of last resort for menorrhagia and, despite its 9% complication rate and high cost, provides permanent relief of menorrhagia symptoms.
Conclusion
While menorrhagia may be attributable to a variety of factors, clinicians can use a few basic parameters (i.e., age, duration of symptoms, and associated symptoms) to narrow the range of differential diagnoses. After ensuring hemodynamic stability, any underlying conditions should be corrected and normal menstrual cycling restored. Hormonal therapy is the mainstay of treatment, with novel delivery mechanisms and greater awareness helping women avoid unnecessary surgery. Hysterectomy, a definitive but costly treatment, should be reserved for patients unresponsive to other modalities.
Ms. Stern is a nurse practitioner with Planned Parenthood of Connecticut in New Haven.
References
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All electronic documents accessed December 7, 2008.