Menorrhagia may be defined as excessive menstrual loss. Objectively, this means measured menstrual loss in excess of 80 ml per menstrual cycle. In clinical practice, it is not possible to routinely perform an objective assessment of menstrual loss, and Menorrhagia is therefore taken to be a complaint of excessive menstrual loss.
A significant population of women complaining of Menorrhagia will have a measured blood loss less than 80 ml per cycle. Menorrhagia is a major reason for gynecological referral. Various methods have been developed for the objective assessment of menstrual loss. These have not been very helpful in the clinical management of Menorrhagia.
Menorrhagia may start anytime from menarche through the reproductive years to menopause and in the postmenopausal women on hormone replacement therapy. It can start suddenly or run a chronic course.
During the normal menstrual cycle, proliferation of endometrium is induced by the effect of oestrogens, while progestogens induce secretory differentiation. For menstruation to occur there is extensive arteriolar vasoconstriction and bleeding occurs as vessels dilate.
The causes of Menorrhagia can vary from a dysfunctional aetiology to the existence of pelvic pathology and rarely to systemic disorders.
Apart from the social and psychological effects of Menorrhagia, the severity can be assessed by estimation of the hemoglobin level and other blood indices and the effect on the iron status. Menorrhagia is the commonest cause of iron deficiency anaemia in the reproductive age women.
Aetiology of Menorrhagia
The causes of Menorrhagia can be categorized into three main groups, namely:
- Dysfunction uterine bleeding (DUB),
- Bleeding due to pelvic pathology,
- Medial disorders including coagulation defects.
DUB is a diagnosis of exclusion. Pelvic causes of Menorrhagia include:
- Uterine fibroids
- Endometrial polyps
- Presence of intra-uterine contraceptive device (IUCD)
- Endometrial hyperplasia;
- Rarely, endometrial cancer.
Large submucous fibroids and pedunculated fibroid polyps are associated with the heaviest degree of loss. The endometrial pathologies that can be diagnosed by hysteroscopy include:
- Submucous fibroids,
Hysteroscopy will also help in confirming the dysfunctional aetiology of Menorrhagia.
Systemic disease occasionally causes Menorrhagia. Systemic causes of Menorrhagia can vary from
- Von Willebrand’s disease and other blood factor deficiency states
- Autoimmune disorders like idiopathic thrombocytopenia and systemic lupus erythomatosus;
- Use of anticoagulants like warfarin
- Chronic liver disease
- Rarely, leukaemia.
Unsuspected pregnancy bleeding can present like and acute episode of Menorrhagia or compliance an ongoing chronic Menorrhagia. Menorrhagia can occur in postmenopausal women taking hormone replacement therapy.
(Peter O Donovan, Paul McGurgan, Walter Prendiville; Conservative Surgery for Menorrhagia; 2002; 33)
Symptoms of Menorrhagia
The word Menorrhagia means excessive flow of blood during the menstruation. In this condition the menstrual period may be regular as to time, or it may come too early, or it may last too long. Excessive flow of blood produces paleness of face, sunken eyes, and is usually attended with lassitude, a sense of oppression in the head, wandering pains in the lack, loins, and lower extremities: sense of weight and pressure in the pelvis; chilliness, cold feet, weak sight, weak pulse and impaired appetite.
Assessment of Menorrhagia
The number of sanitary towels used, duration of bleeding, or passage of clots has been shown to have little or no correlation with actual blood lost. However, complaints of ‘flooding’ (leakage of heavy blood onto clothes are indicative of heavy menstrual loss. Similarly, severity of bleeding can be assessed by determining the impact it has on the individuals’ quality of life. It is important therefore, to ask about the degree of disability experienced, such as time lost from work, or becoming housebound during menses owing to fear of social embarrassment from an episode of flooding in public.
The patient should also be questioned about symptoms suggestive of anaemia. A history of irregular bleeding, dyspareunia, pelvic pain, inter-menstrual or postcoital bleeding may raise the suspicion of underlying pathology.
A history suggestive of systemic disease such as thyroid disorder or a clotting abnormality would signal that further investigation for such causes would be required. The patient should also be questioned about risk of factors for endometrial cancer such as use of unopposed oestrogen, polycystic ovary syndrome and family history or endometrial or colon cancer. It is also important to establish if the patient has a history of thromboembolism, as many medical treatments for Menorrhagia are hormonal and thus their use may be contraindicated.
What are the examinations can be done in case of Menorrhagia?
The patient should be examined for signs suggestive of anaemia. An abdominal, bimanual and speculum examination should be performed. An enlarged bulky uterus suggests uterine fibroids, and tenderness suggests endometriosis, pelvic inflammatory disease or Adenomyosis.
Full blood count to exclude anaemia, with iron supplementation offered if required.
Thyroid function tests and tests of coagulation should only be performed if there are features suggestive of this in the history. No other endocrine tests are necessary.
Ultrasound – A pelvic ultrasound scan should be performed if history or examination suggests structural uterine pathology, or if it is not possible to assess the uterus clinically because of obesity. The site and size of abnormalities such as fibroids can be determined, together with assessment of the ovaries.
Endometrial assessment should be performed in all women > 40 years, or younger women with persistent Menorrhagia, irregular bleeding, or for whom there are risk factors for endometrial cancer. This can take the form of an endometrial biopsy or a hysteroscopy, both of which can be carried out either as an outpatient or inpatient.