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INDEX

  • Menorrhagia –Diagnosis and Treatment
  • Context
  • Diagnostic Process
  • Presentation:
  • Causes of anovulation:
  • Differential Diagnosis (PALM-COEIN)
  • Physical Exam:
  • Investigations and Imaging:
  • Recommended Treatment
  • Considerations
  • Emergency Dept
  • Surgical Management
  • Quality Of Evidence?
  • Related Information
  • Relevant Resources

Menorrhagia –Diagnosis and Treatment

Metabolic / Endocrine, Obstetrics and Gynecology

Last Reviewed on Apr 04, 2021
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By Julian Marsden,Brenna Mackay

Context

Menorrhagia, or prolonged or excessive uterine bleeding, can have a significant impact on quality of life.

  • 75% of hysterectomies relate to fibroids/menorrhagia worldwide.
  • ~1 in 20 women between 30-49 years of age will present with heavy menstruation each year.
  • Menstrual irregularities most frequent in adolescence and perimenopause.
  • Clinical starting point: rule out pregnancy.

Approach in non-pregnant women of reproductive age:

    • Rapid assessment of clinical picture and hemodynamic stability.
    • Determine etiology.
      • Same for acute and chronic bleeding.
    •  Choose appropriate treatment.

Diagnostic Process

Presentation:

    • Menstrual bleeding that lasts >7 days.
    • Heavy bleeding (>80cc of blood loss/cycle – hard to quantify clinically).
      • Needing to change pad or tampon after <2hrs.
      • Passing clots larger than the size of a quarter.
    • Bleeding that significantly affects the quality of life.
    • Some patients may have anemia, fatigue, and weakness.

 

  • Anovulatory cycles are a common cause of menorrhagia:
    • More common at menarche and menopause and with PCOS and obesity.
    • Symptoms classically include: hx of irregular periods, late period, and/or mid-cycle spotting.
    • Note: spotting can also be a symptom of implantation bleedingin early pregnancy and with normal ovulation.
    • Changes to PMS symptoms due to different hormone levels.

 

Causes of anovulation:

      • Severe changes to diet and/or exercise.
      • Prolonged stress.
      • Disruption to routine.
      • Existing medical conditions such as PCOS.
      • Menopause.

 

Differential Diagnosis (PALM-COEIN)

    • Structural (PALM) and non-structural (COEIN) causes:
      • Structural:
        • Polyp: 16% of cases*.
        • Adenomyosis: 5%.
        • Leiomyoma: 12%*.
        • Malignancy and hyperplasia: 2%.
      • Non-structural:
        • Coagulopathy: 1%.
        • Ovulatory dysfunction: 58%*.
        • Endometrial: 2%.
        • Iatrogenic: 2%.
        • Not yet classified 1%.

Physical Exam:

    • Initial assessment à signs of hypovolemia and anemia?
    • Confirm bleeding is uterine
    • Rule out any trauma/abnormality to the genital tract, vagina or cervix.
    • Uterine enlargement or irregularity à potential structural cause
    • Consider initiating treatment if low risk of malignancy, fibroids, uterine or histological abnormality or adenomyosis

Investigations and Imaging:

    • General laboratory Tests
      • All patients:
        • CBC, pregnancy test, blood type and cross match if unstable or symptomatic anemia.
      • Heavy bleeding from menarche / family history of bleeding disorders:
        • INR, PTT, Fibrinogen, von Willebrand factor antigen, Factor VIII
      • Depending on clinical picture, can also consider:
        • TSH, serum Fe, total iron binding capacity, ferritin, liver function tests, infection (chlamydia trachomatis).
      • Structural Entities:
        • Imaging:
          • 1st line: ultrasound (often transvaginal).
        • Endometrial Biopsy Indications:
          • >40 yrs of age.
          • Any risk factor for endometrial cancer: >90kg, nulliparity, Polycystic Ovary Syndrome (PCOS), diabetes, hereditary nonpolyposis colorectal cancer (HNPCC – also known as Lynch Syndrome).
          • Failure of medical treatment.
          • Significant intermenstrual bleeding (IMB).
          • Woman of any age with past anovulatory cycles—patient describes irregular or infrequent periods on hx.
          • Postmenopausal women with Endometrial Thickening >4mm on ultrasound.

Recommended Treatment

Considerations

Clinical stability, suspected etiology, comorbidities and wishes for future fertility.

  • Menorrhagia may present with significant anemia and require emergent care.

 

 

Emergency Dept

  1. NSAIDsare the first-line medical therapy in ovulatory menorrhagia.
  • Average reduction of 20-46% in menstrual blood flow.
  • Reduce prostaglandin levels by inhibiting cyclooxygenase (higher PG levels in endometrium of pts who have menorrhagia cf. non-menorrhagia).
  • 5 days of the entire cycle, limiting stomach upset from NSAIDs.
  • Food for mild bleeding and pain.
  1. Tranexamic acid.
  • Better than NSAIDS.
  • Blocks lysine binding on plasminogen and prevents fibrin degradation.
  • 1 g PO QID x 4/7.
  • Adverse effects: N, V, D, Venous Thromboembolism (odds ratio for VTE = 3.20 (95% CI 0.65–15.78).
  1. Provera.
  • Progestin (medroxyprogesterone) is the most frequently prescribed medicine for menorrhagia (especially anovulatory).
  • Significant reduction in menstrual blood flow when used alone.
  • Works as an antiestrogen by minimizing the effects of estrogen on target cells, thereby maintaining the endometrium in a state of down-regulation.
  • Adverse effects: weight gain, headaches, edema, and depression.

*Refer to gynecology if treatments are unsuccessful at controlling symptoms, symptoms are severe, or a large structural defect is identified.

 

Surgical Management

    • Endometrial Ablation.
      • Similar patient satisfaction, less anesthetic, and fewer risks of complication than hysteroscopic ablation.
    • Hysteroscopic myomectomy: for bleeding secondary to fibroids.
      • Hysterectomy = definitive treatment for abnormal uterine bleeding.

Quality Of Evidence?

Justification

  • Recommendations based on systematic reviews and three main clinical guidelines: Moderate
Moderate

Related Information

OTHER RELEVANT INFORMATION

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