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    Menorrhagia –Diagnosis and Treatment

    Metabolic / Endocrine, Obstetrics and Gynecology

    Last Updated Apr 04, 2021
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    By Julian Marsden, Brenna Mackay


    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


      • 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


    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?


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

    Related Information


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