Menorrhagia – Causes, Symptoms, Diagnosis, Treatment

Menorrhagia is prolonged and excessively heavy menstrual bleeding at regular menstrual cycle intervals. Although several factors (e.g. anatomical defects or growths in the womb, blood component abnormality, or hormonal imbalance) may be implicated, the cause of the abnormal uterine bleeding is often unknown.

Menorrhagia is is a gynecological disease condition with menstrual bleeding that lasts more than 7 days. Menorrhagia (also known as heavy menstrual bleeding) is defined as heavy, but regular, menstrual bleeding. Menorrhagia menstruation at the regular cyclical interval with excessive flow and duration; clinically, blood loss is in excess of 80 ml per cycle; or menses last longer than 7 days to more.

Types of Menorrhagia

• Idiopathic ovulatory menorrhagia – is regular heavy bleeding in the absence of recognizable pelvic pathology or a general bleeding disorder.
• Objective menorrhagia – is taken to be a total menstrual blood loss of 80 mL or more in each menstruation. It is difficult to incorporate the objective measurement of menstrual blood loss into everyday practice. Subjectively, menorrhagia may be defined as a complaint of regular excessive menstrual blood loss that interferes with the woman’s physical, emotional, social, and material quality of life, and that can occur alone or in combination with other symptoms.
• Metrorrhagia – intermenstrual bleeding occurring at any time between menstrual periods17p1355
• Hypomenorrhea – (cryptomenorrhea)-unusually light menstrual flow, sometimes only spotting, or a deficient amount of menstrual flow17p1052
• Menometrorrhagia – bleeding that occurs at irregular intervals or bleeding during and between menstrual periods in which amount and duration of bleeding may also vary17p1339
• Polymenorrhea – menstrual periods occurring with abnormal frequency17p1726
• Oligomenorrhea – periods that occur more than 35 days apart or scanty or infrequent menstrual flow17p1516

Dysfunctional menses – abnormal uterine bleeding without any obvious structural or systemic abnormality8,19

Causes of Menorrhagia

• Hormone imbalance – In a normal menstrual cycle, there has a balance between the hormones estrogen and progesterone regulates that regulate the makeup of the lining of the uterus (endometrium), which is shed during menstruation. If a hormone imbalance occurs in early or late life, the endometrium develops automatically in excess and eventually sheds it by the way of heavy menstrual bleeding.
• Dysfunction of the ovaries – It is another problem that is your ovaries don’t release healthy an egg (ovulate) during a menstrual cycle (anovulation), In this case, your body doesn’t produce enough hormone progesterone, as it would during a normal menstrual cycle. This may lead to hormone imbalance and may result in menorrhagia.
• Uterine fibroids – Uterine fibroita or cyst form in the ovary noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.
• Polyps – Small, benign growths on the lining of the uterus (uterine polyps) may cause heavy or prolonged menstrual bleeding.
• Adenomyosis – It is a condition embedded with the endometrium muscle, uterine muscle, the blood vessel is causing the heavy bleeding and painful bleeding during the times of period.
• Intrauterine device (IUD) – It is a well-known and widely used product that is randomly used as a birth control device. It has the side effect of using a nonhormonal intrauterine device for birth control. Your doctor will help you to plan the alternative management options.
• Pregnancy complications – Pregnancy-related complications are also seen in a heavy, late period of time and may be due to a miscarriage. Another cause of heavy bleeding during pregnancy includes an unusual location and abnormal position of the placenta, such as a low-lying placenta or placenta previa.
• Cancer – Uterine cancer and cervical cancer can cause excessive menstrual bleeding, especially if you are postmenopausal or have had an abnormal Pap test in the past.
• Inherited bleeding disorders –  It is one of the basic or another problems such as von Willebrand’s disease, a condition in which an important blood-clotting factor is deficient or impaired can cause abnormal menstrual bleeding.
• Medications – Certain medications, including anti-inflammatory medications, hormonal medications such as estrogen and progestins, and anticoagulants such as warfarin (Coumadin, Jantoven) or enoxaparin (Lovenox), can contribute to heavy or prolonged menstrual bleeding.

Others Cause May Consideration

Excessive menses but normal cycle – Painless

• Fibroids (leiomyoma) — fibroids in the wall of the uterus cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrial surface area.
• Coagulation defects (rare) — with the shedding of an endometrial lining’s blood vessels, a normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities
• Endometrial cancer (cancer of the uterine lining) — bleeding can also be irregular, in between periods, or after menopause (post-menopausal bleeding or PMB)
• Endometrial polyp
• Omega 6 and prostaglandins – HMB is associated with increased omega-6 AA in uterine tissues.^[rx] The endometrium of women with HMB have higher levels of prostaglandin (E2, F2alpha, and others) when compared with women with normal menses.^[rx] It is thought that prostaglandins are a by-product of omega 6 build-up.^[rx]

Painful (ie associated with dysmenorrhea)

• Pelvic inflammatory disease
• Endometriosis – an extension of the endometrial tissue outside of the uterus tries to shed causing painful and abnormal bleeds
• Adenomyosis – an extension of the endometrial tissue into the wall of the uterus tries to shed causing painful and abnormal bleeds
• Pregnancy-related complication (i.e. miscarriage)
• Short cycle (less than 21 days) but normal menses.
• Short term cycle and over excessive menses due to ovarian dysfunction and may lead to secondary blockage of blood vessels by tumors.
• Polycystic ovary syndrome.^[rx]
• Systemic causes: thyroid disease, excessive emotional/physical stress.^[rx]
• Sexually transmitted infection.^[rx]

Hormonal Abnormalities

• Luteal phase defects
• Stress
• Exogenous hormones
• Ovarian Cysts

Mechanical Abnormalities

• Uterine Polyps
• Uterine Fibroids
• Intrauterine devices
• Atopic pregnancy
• Pregnancy

Clotting Abnormalities

• Drug-induced hemorrhage
• Dysproteinemias
• Disseminated intravascular coagulation
• Severe hepatic disease
• Primary fibrinolysis

Diagnosis of Menorrhagia

Your doctor may ask for information about

• age of your and when you got your first feeling of the period
• Length of your menstrual cycle
• Number of days your period lasts
• Number of days your period is heavy
• Quality of life during your period
• Family members with a history of heavy menstrual bleeding
• The stress you are facing
• Weight problems
• Current medications

Imaging and Lab Test

• Full blood count – Hemoglobin concentration is a surrogate assessment for excessive menstrual loss.^[rx] Other indices within the full blood count may more accurately assess iron state.^[rx] Full blood count should be undertaken in all women presenting with menorrhagia
• A pregnancy test – should always be performed in women of childbearing age, regardless of their history of sexual activity. Outpatient studies often consist of tests to assess for anemia and blood dyscrasias (ferritin, coagulation studies, complete blood count, and bleeding studies), tests to assess for thyroid disease (TSH and free T4), tests to assess for liver disease, and even advanced procedures (hysteroscopy) to look for anatomical causes of bleeding.
• Coagulation screen – Tests for coagulopathies such as von Willebrand’s disease should only be undertaken when specifically indicated by the history
• Thyroid function tests – There is little evidence to link hypothyroidism with excessive menstrual loss^[rx] and no evidence for hyperthyroidism to be a cause.^[rx] Thyroid function tests should not be routinely undertaken
• Other endocrine investigations – No significant endocrine abnormality has been detected in menorrhagia.^[rx,rx There is no indication for any endocrine investigation
• Pelvic ultrasound – Routine pelvic ultrasound has little place in evaluating the primary complaint of excessive menstrual loss.^[rx] It is of value in evaluating other pelvic disorders discovered during a clinical examination
• Endometrial sampling – it is a part of the initial assessment, there is no place for endometrial sampling. So you have to identify another option. ^[rx] Sampling should be combined with further examination of the endometrial cavity, such as hysteroscopy, in selected cases only. Selected cases would include women over 40, women complaining of intermenstrual bleeding, and after a failed trial of medical treatment
• Pap test – It is one kind of test in where the cells or tissue from your cervix are collected and tested for infection, inflammation or changes that may be cancerous or may lead to cancer.
• Endometrial biopsy –  The endometrial biopsy is taken to identify the cellular problem, hormonal problem, tumor antigen anad other types of disease
• Sonohysterography – It is a special kind of test that is performed by injected through a tube into your uterus by way of your vagina and cervix. Your doctor then uses an ultrasound to look for problems in the lining of your uterus.
• Hysteroscopy – This exam involves inserting a thin, lighted instrument through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus in where it is normal or not.
• Electric hysterogram – This ultrasound scan is done after fluid is injected through a tube into the uterus by way of your vagina and cervix. This lets your doctor look for problems in the lining of your uterus. Mild to moderate cramping or pressure can be felt during this procedure.
• Hysteroscopy – It is a surgical procedure to look at the internal organ, cyst, fibrosis to remove it permanently. You might be given drugs to put you to sleep (this is known as “general anesthesia) or drugs simply to numb the area being looked at (this is called local anesthesia).
• Dilation and Curettage (D&C) – This is a procedure (or test) that can be used to find and treat the cause of bleeding. During a D&C, the inside lining of your uterus is scraped and looked at to see what might be causing the bleeding. A D&C is a simple procedure. Most often it is done in an operating room, but you will not have to stay in the hospital afterward. You might be given drugs to make you sleep during the procedure, or you might be given something that will numb only the area to be worked on.

Treatment of Menorrhagia

Medications

These have been ranked by the UK’s National Institute for Health and Clinical Excellence:^[rx]

• First-line
  • An intrauterine device with progesterone
• Second Line
  • Tranexamic acid an antifibrinolytic agent
  • Nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Combined oral contraceptive pills to prevent the proliferation of the endometrium
• Third line
  • An oral progestogen (e.g. norethisterone), to prevent the proliferation of the endometrium
  • An injected progestogen (e.g. Depo Provera)
• Other options
  • Gonadotropin-releasing hormone agonist

Sample Treatment Plan for Chronic Recurring Menorrhagia

• Bioflavonoids, 1000 mg twice per day
• Vitamin A 60,000IU per day
• Chaste tree (standardized extract) 175 mg per day; or ½–1 tsp daily
• Combination herbal product using astringents and uterine tonics
• Consider natural progesterone cream, ¼ to ½ tsp, 12–21 days/month
• Oral micronized progesterone: 200–300 mg per day for 7–12 days followed by a cyclic hormone product for 21 days on and 7 days off

Drug Therapy

• Iron supplements – To get more iron into your blood to help it carry oxygen if you show signs of anemia.
• Ibuprofen – It is the first choice of pain madication to reduce pain, menstrual cramps, and the amount of bleeding. In some women, not specific NSAIDs can increase the risk of bleeding.
• Intrauterine contraception (IUC) – It is the most common and intrauterine device that are used to regulate the normal men, reduce the amount of bleeding that are caused by specific drug or more common reason.
• Desmopressin Nasal Spray Stimate – To stop bleeding in people who have certain bleeding disorders, such as von Willebrand disease and mild hemophilia, by releasing a clotting protein or “factor”, stored in the lining of the blood vessels that help the blood to clot and temporarily increasing the level of these proteins in the blood.
• Antifibrinolytic medicines (aminocaproic acid) – To reduce the amount of bleeding by stopping a clot from breaking down once it has formed.
• Prostaglandin inhibitors – These are nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin or ibuprofen. They help reduce cramping and the amount you bleed.
• Anti-inflammatory medication like NSAIDs – may also be used. NSAIDs are the first-line medications in ovulatory heavy menstrual bleeding, resulting in an average reduction of 20-46% in menstrual blood flow. NSAIDs may be more effective than placebo in terms of reducing blood loss increasing women’s subjective perception of improvement, they may be less effective than tranexamic acid. It is uncertain if there is any difference between NSAIDs and tranexamic acid in terms of women’s subjective perception of bleeding.^[rx] For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.^[rx]
• Tranexamic acid – reduces menstrual blood loss by about half, and nonsteroidal anti-inflammatory drugs reduce it by about a third. Tranexamic acid tablets may also reduce loss by up to 50%.^[rx] This may be combined with hormonal medication previously mentioned.^[rx]NICE guidelines say that for women (with HMB and no identified pathology or fibroids less than 3 cm in diameter) who do not wish to have the pharmacological treatment and who do not want to conserve their fertility, surgical options could be considered as a first-line treatment option. And options are hysterectomy and second-generation endometrial ablation. With hysterectomy more effective than second-generation endometrial ablation.^[rx]
• Vitamin K and chlorophyll – Although bleeding time and prothrombin levels in women with menorrhagia are typically normal, the use of vitamin K (historically in the form of crude preparations of chlorophyll) has clinical and limited research support.”^[rx]
• Hormonal therapy – for menorrhagia has been progestogens given during the luteal phase of the cycle. Such treatments are ineffective. Despite this, they remain the first choice of many general practitioners and gynecologists.^[rx,rx] Progestogens are effective when given for 21 days in each cycle, but the side effects may be such that patients choose not to continue with treatment.^[rx] Although progestogens have a contraceptive effect, their use in this way may not be the best choice when contraception is required by the patient.
• The combined contraceptive pill – is both an effective contraceptive and treatment of menorrhagia compared with other medical treatments.^[rx] This statement, however, cannot be expanded upon because good-quality data are lacking,^[rx] and the use of the contraceptive pill in this area has been insufficiently studied. Nevertheless, like cyclical progestogens, combined oral contraceptives are useful for anovulatory bleeding because they impose a cycle.
• Vitamin B Complex – There may be a correlation between a deficiency of vitamin B and menorrhagia. With Vitamin B complex deficiencies, the liver loses it ability to inactivate estrogen. Some cases of menorrhagia are due to excess estrogen’s effect on the endometrium. The vitamin B complex may help to normalize estrogen metabolism.
• Vitamin C and Bioflavonoids – Vitamin C, along with bioflavonoids, help reduce heavy bleeding by making the capillaries stronger and preventing them from becoming fragile. In one small study with 18 women who had heavy menstrual bleeding, bleeding improved in 16 out of the 18 patients when the women took Vitamin C and bioflavonoids.^[rx] In addition, vitamin C can also help women who have suffered from iron deficiency from menorrhagia by increasing iron absorbency.

Surgery

• Dilation and curettage (D&C) – is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if spontaneous abortion is incomplete^[rx] In this procedure, your doctor opens (dilates) your cervix and then scrapes to suctions tissue from the lining wall of your uterus to reduce over menstrual bleeding.
• Endometrial ablation – is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy.^[rx] For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply. During the time of uterine artery embolization, the surgeon may pass a catheter through the large artery or femoral artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with medicine that may decrease blood flow to the fibroid.
• Uterine artery embolization (UAE) – The rate of serious complications is comparable to that of myomectomy or hysterectomy; however, UAE presents an increased risk of minor complications and requiring surgery within two to five years.^[rx]
• Hysteroscopic myomectomy – to remove fibroids over 3 cm in diameter
• Focused ultrasound surgery – Similar to uterine artery embolization, focused ultrasound surgery treats bleeding caused by fibroids by shrinking the fibroids. This procedure uses ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure.
• Myomectomy – It is the surgical procedure to remove the uterine fibrous tissue. It may vary depending on the size, number, and location of the fibroids tissue and cyst. Depending on the fibrous condition your surgeon may choose to perform the myomectomy using open abdominal surgery, through laparoscopically, or through the vagina and cervix (hysteroscopically).
• Endometrial ablation – It is a typres of the process of destroying (ablating) the lining of your uterus (endometrium). The procedure uses a laser, radiofrequency, or heats applied to the endometrium to destroy the tissue. After taking endometrial ablation, most of the women have much lighter periods. Pregnancy after endometrial ablation may have many associated complications. If you have an endometrial ablation, the use of reliable or permanent contraception until menopause is recommended.

References

1. https://www.ncbi.nlm.nih.gov/books/NBK279294/
2. https://www.ncbi.nlm.nih.gov/books/NBK470230/
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907973/
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4574688/
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2077876/
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070839/
7. https://en.wikipedia.org/wiki/Heavy_menstrual_bleeding
8. https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
9. https://www.nhs.uk/conditions/heavy-periods/treatment/

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