Menorrhagia

Summary

Menorrhagia is defined as excessive, prolonged, and regular menstrual bleeding that exceeds 80 mL per cycle or significantly impacts a woman's quality of life. Etiologically, it is divided into dysfunctional uterine bleeding including ovulatory and anovulatory types and organic causes, which can be genital or systemic. Diagnosis involves CBC, thyroid tests, pelvic ultrasound, and endometrial biopsy when indicated. Management includes correcting anemia and using hormonal or non-hormonal pharmacologic treatments such as NSAIDs, tranexamic acid, COCs, progestogens, or the LNG-IUD. Refractory or structural cases may require surgical options like endometrial ablation or hysterectomy.

Definition

excessive, prolonged, and regular menstrual bleeding that objectively exceeds 80 mL per cycle or subjectively interferes with a woman's quality of life. It is a leading cause of iron-deficiency anemia and one of the most common reasons for gynecological referrals and hysterectomy in developed countries.

Etiology

Menorrhagia is broadly classified into two categories: Dysfunctional Uterine Bleeding (DUB) and organic causes, with DUB accounting for approximately 60% of cases.

1. Dysfunctional Uterine Bleeding (Non-organic Menorrhagia, 60%):
   DUB refers to excessive menstrual bleeding in the absence of structural (genital) or systemic pathology.
   1. Ovulatory DUB (most common):
      Occurs primarily in reproductive-aged women. It results from disordered endometrial function due to prostaglandin imbalance (↑PGE₂/↓PGF₂α ratio) and enhanced fibrinolytic activity.
   2. Anovulatory DUB:
      Common at the extremes of reproductive life and in chronic anovulatory states like polycystic ovary syndrome (PCOS).
2. Organic Menorrhagia (40%):
   Organic causes are responsible for 40% of cases and can be divided into genital and systemic origins.
   1. Genital Causes:
      • Uterine fibroids (especially submucosal)
      • Endometrial hyperplasia or carcinoma
      • Adenomyosis and endometriosis
      • Pelvic inflammatory disease (PID)
      • Copper IUDs
      • Ovarian tumors (e.g., granulosa and theca cell tumors)
   2. Systemic Causes:
      • Endocrine: Hypothyroidism (myxedema)
      • Medications: Anticoagulants, aspirin, tamoxifen
      • Hematologic: ITP, von Willebrand disease, coagulation factor deficiencies, Glanzmann’s thrombasthenia
      • Hepatic failure

Investigations

• Initial: CBC, thyroid function tests, pelvic ultrasound
• Endometrial biopsy: Essential in women ≥40 years or with risk factors for malignancy; best performed under hysteroscopic guidance
• Coagulation profile: Reserved for suspected bleeding disorders

Management

Acute Menorrhagia

• Correction of anemia
• High-dose oral progestogens (e.g., norethisterone 10 mg TID)
• Other hormonal agents: GnRH analogs, IV conjugated estrogens
• Dilation and curettage (D&C): For non-responders

Chronic Menorrhagia

1. Organic Causes
   • Manage based on underlying pathology 
2. Dysfunctional Uterine Bleeding
   • Adolescents:
     • Reassurance and education
     • Iron supplementation 
     • Non-hormonal: NSAIDs (e.g., mefenamic acid), tranexamic acid
     • Hormonal: COCs, oral progestogens
   • Reproductive-Aged Women:
     • Same pharmacologic approach as above
     • Mirena (LNG-IUD): Highly effective in reducing MBL by up to 90%, also provides contraception
   • Perimenopausal Women:
     • Similar to reproductive-aged management
     • Surgical options if medical therapy fails:
       • Endometrial ablation/resection
       • Hysterectomy

 

Pharmacologic Options Overview

 

Surgical Options

• Endometrial Ablation/Resection.
• Hysterectomy.