menorrhagia

Introduction

Excessively heavy or prolonged menstrual bleeding. (also see vaginal bleeding)

Etiology

• regular menses (ovulatory cycles)
• fibroids (most common cause)
• endometrial polyps
• adenomyosis
• endometrial hyperplasia
• endometrial carcinoma
• hemostatic defects (47%)
  • platelet aggregation abnormality (44%)
  • vWF deficiency (7-20%)
  • coagulation factor deficiency (5%)
  • anticoagulation
    • 22-65% with warfarin
    • 32% with rivaroxaban
    • 28% with apixaban
    • 25% with edoxaban
• irregular meneses (anovulatory cycles)
  • hyperthyroidism, hypothyroidism
  • polycystic ovary disease
  • hyperprolactineuma

Epidemiology

• adolescents-perimenopausal women
  • hemostatic defects common in all age groups

Clinical manifestations

• passing clots larger than a quarter, duration > 8 days, & iron-deficiency anemia associated with a higher risk of underlying bleeding disorder

Laboratory

• pregnancy test if premenopausal
• complete blood count (CBC)
  • anemia (41% with Hgb < 12 g/dL)
• iron studies
• consider screening for von Willebrand disease
• consider serum TSH, coagulation tests, serum prolactin

Diagnostic procedures

• endometrial biopsy
  • premenopausal women >= 45 years
  • premenopausal women with risk factors for endometrial cancer
    • obesity (BMI >= 30), polycystic ovary syndrome (unapposed estrogen), genetic syndromes (Lynch syndrome, Cowden syndrome)
  • postmenopausal women if endometrial thickness is > 4 mm on pelvic ultrasound
  • failure of medical management

Radiology

• pelvic ultrasound
  • postmenopausal women
    • provides better & more cost-effective imaging than pelvic MRI
    • assess structural abnormalities, endometrial thickness
  • premenopausal woman with enlarged uterus
    • optimal management of premenopausal women with normal size uterus has not been determined

Differential diagnosis

• abnormal uterine bleeding

Management

• endometrial biopsy to evaluate for endometrial cancer as indicated (see Diagnostic procedures/Special laboratory above)
• progesterone-releasing intrauterine device
  • levonorgestrel (Mirena)
• oral contraceptive: estradiol/dienogest (Natazia)
• cyclic progesterone
• tranexamic acid in oral doses every 6-8 hours or a single 10-mg/kg intravenous dose to control acute hemorrhaging
• RBC transfusion for hemodynamically significant anemia
• surgical intervention as needed
  • endometrial ablation
    • uterine artery embolization

More general terms

• menstrual disorder
• vaginal bleeding; abnormal uterine bleeding; anovulatory bleeding

Additional terms

• menometrorrhagia
• metrorrhagia
• polymenorrhagia