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.

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:
        • 1^st 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.

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.

2. 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).

3. 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.

1. HealthLink BC – Abnormal Uterine Bleeding
   Healthwise Staff July 17, 2020.
   HealthLink BC (online)

   
   

2. Heavy Menstrual Bleeding
   Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities (December 20, 2017)
   Centers for Disease Control and Prevention Content

   
   

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5. Heavy menstrual bleeding: assessment and management.
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7. Prevalence of abnormal uterine bleeding according to new International Federation of Gynecology and Obstetrics classification in Chinese women of reproductive age: A cross-sectional study.
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