Metrorrhagia – Causes, Symptoms, Diagnosis, Treatment

Metrorrhagia is a gynecological disorder that is caused by uterine bleeding with regular intervals,s particularly during the expected menstrual period. It may be caused by a variety of problem that falls into nutritional deficiency anemia, poor diet, iron defeciency anemia. The symptoms of metrorrhagia maybe the underlying symptoms such as hormonal imbalance, endometritis, uterine fibrosis and cancer.

Causes of Metrorrhagia

Intermittent spotting between periods can result from any of numerous reproductive system disorders.

Neoplasia

  • Cervical cancer
  • Uterine cancer
  • Vaginal cancer
  • Endometrial cancer
  • Primary fallopian tube cancer
  • Ovarian cancer

Inflammation

  • Cervicitis
  • Endometritis
  • Vaginitis
  • Sexually Transmitted Infections
  • Pelvic inflammatory disease

Endometrial abnormalities

  • Endometriosis
  • Adenomyosis
  • Uterine leiomyomas
  • Endometrial hyperplasia
  • Polyps

Endocrinological causes

  • Hormone imbalance
  • Dysfunctional uterine bleeding
  • Diets which induce ketosis, such as the Atkins diet
  • polycystic ovarian syndrome

Bleeding disorders

  • Von Willebrand Disease
  • Pancytopenia due to leukemia

Drug-induced

  • Use of progestin-only contraceptives, such as Depo Provera
  • Change in oral contraception
  • Overdose of anticoagulant medication or Aspirine abuse

Traumatic causes

  • Automutilation
  • Sexual abuse or rape

Related to pregnancy

  • Implantation bleeding
  • Ectopic pregnancy
  • (Incomplete) miscarriage

Other causes

  • Enlarged uterus with menorrhea

Symptoms of Metrorrhagia

You may feel the following  sign and symptoms of metrorrhagia
  • Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
  • Needing to use double sanitary protection to control your menstrual flow
  • Needing to wake up to change sanitary protection during the night
  • Bleeding for longer than a week
  • Passing blood clots larger than a quarter
  • Restricting daily activities due to heavy menstrual flow
  • Symptoms of anemia, such as tiredness, fatigue, or shortness of breath
  • Menstrual flow that soaks through one or more sanitary pads every hour
  • The need to use double sanitary protection to control your menstrual flow
  • The menstrual period lasts more than seven days
  • Menstrual flow that includes large blood clots
  • Excessive and prolonged menses may lead to anemia,
  • Pallor
  • Tiredness
  • Fatigue
  • Shortness of breath

According to the CDC

You might have metrorrhagia if you:

  • Have a menstrual flow that soaks through one or more pads or tampons every hour for several hours in a row.
  • You have to need to double up on pads to control your menstrual flow.
  • You may have a need to change pads or tampons during the night.
  • Have menstrual periods lasting more than 7 days. or more
  • Menstrual flow with blood clots the size of a quarter or larger you may found
  • Have a heavy menstrual flow that keeps you from doing the things you would do normally.
  • Have constant pain in the lower part of the stomach during your periods.
  • Are tired, lack energy or fatique, or are short of breath.


Diagnosis of Metrorrhagia

Metrorrhagia is diagnosed by your doctor through a series of questions about your medical history and menstrual cycles. Naturally for women with menorrhagia bleeding may last for more than 7 days and more blood is lost (80 ml compared to 60 ml).

Your doctor may ask for information about:

  • Your age when you got your first period and your feeling
  • The length of your menstrual cycle may be prolonged or not
  • 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. Other indices within the full blood count may more accurately assess iron state. 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 history.
  • Thyroid function tests – There is little evidence to link hypothyroidism with the excessive menstrual loss and no evidence for hyperthyroidism to be a cause. Thyroid function tests should not be routinely undertaken
  • Other endocrine investigations – No significant endocrine abnormality has been detected in metrorrhagia., 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. It is of value in evaluating other pelvic disorders discovered during a clinical examination
  • Endometrial sampling – As part of the initial assessment, there is no place for endometrial sampling. Sampling should be combined with further assessment of the endometrial cavity, for example, hysteroscopy, in selected cases only.
  • Pap test – It is one kind of test the tissue or cell are taken to investigate tumor, metastasis, abnormal growth of tissue, and others abnormality.
  • Endometrial biopsy – Tissue samples are taken from the inside lining of your uterus or “endometrium” to find out if you have cancer or other abnormal cells. You might feel as if you were having a bad menstrual cramp while this test is being done.
  • Sonohysterography – The test is done by injecting a fluid,  through a tube into your uterus by way of your vagina and cervix. Your doctor or pathologist then uses an ultrasound to look for problems in the inner 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.
  • 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 done in the last stage of the disease when the previous test ate failed to identify the problem. This is done the procedure to look deeply inside the uterus by using a tiny tool to see the fibrous tissue, cyst, polyps, and associate others problem that are causing bleeding.
  • Dilation and Curettage (D&C) – It is one kind of test that is performed to identify the internal bleeding, lining of uterus, tendon, cartilage, and fibrous tissue In most often given drugs to make you sleep during the procedure, or you might be given something that will apply numb and anesthesia only the area to be worked on.

Treatment of Metrorrhagia

Medications

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

  • Oral Contraceptive
    • Switch to Levonorgestrel containing pill
    • Avoid when Oral Contraceptive is contraindicated (e.g. Tobacco users over age 35 years)
    • Limit Ethinyl Estradiol to no more than 35 mcg
      1. Lower Estrogen is not associated with bleeding
  • Medroxyprogesterone acetate (Provera)
    • Provera 10 mg oral daily for 10-14 days per month
  • Norethindrone (Aygestin)
    • Dose: 5 mg PO tid cycle days 15 to 25
  • Micronized Progesterone (Prometrium)
    • Dose: 200 mg PO qd for cycle days 12 to 25
  • Levonorgetrel-Releasing IUD (Mirena)
    • IUD containing 52 mg Levonorgestrel
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 (Advil) – To help reduce pain, menstrual cramps, and the amount of bleeding. In some women, NSAIDs can increase the risk of bleeding.
  • Intrauterine contraception (IUC) – To help make periods more regular and reduce the amount of bleeding through drug-releasing devices placed into the uterus.
  • 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.”
  • 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., 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. 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. This statement, however, cannot be expanded upon because good-quality data are lacking, 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 looses 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. In addition, vitamin C can also help women who have suffered from iron deficiency from menorrhagia by increasing iron absorbency.


Specific hormonal contraceptives for the treatment of metrorrhagia

Estrogen: EE Progestin Comments
Combined hormonal contraceptives
Combined oral contraceptive pills Packaged as 21 d of active pills or 21 d of active pills + 7 d of placebo pills
20 μg EE 1 mg norethindrone Available in an extended cycle regimen with 24 d of active pills + 4 d of placebo
30 μg EE 1.5 mg norethindrone —
35 μg EE 1 mg norethindrone —
20 μg EE 0.1 mg levonorgestrel —
20 μg EE 90 μg levonorgestrel Marketed as a continuous regimen
30 μg EE 1.5 mg levonorgestrel Available in an extended cycle regimen with 84 d of active pills + 7 d of placebo or 10 μg of EE
Patch 20 μg EE daily 150 μg of norelgestromin daily Applied weekly for 3 wk out of 4
Ring 15 μg EE daily 120 mcg of etonogestrel daily Worn 3 wk out of 4
Progestin-only contraceptives
Pills — 0.35 mg norethindrone Daily
Intramuscular injection — 150 mg DMPA Every 3 mo
Subcutaneous injection — 104 mg DMPA Every 3 mo
Subcutaneous implant — 68 mg etonogestrel Slowly released over ≥3 y; ∼60 μg daily after 3 mo, which slowly decreases to 30 μg daily at the end of 2 y
Intrauterine device — 52 mg levonorgestrel Release rate of 20 μg daily, FDA-approved for 5 y of use
— 13.5 mg levonorgestrel Release rate of 14 μg daily, FDA approved for 3 y of use

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 or suctions tissue from the lining of your uterus to reduce menstrual bleeding. Although this procedure is common and often treats acute or active bleeding successfully, you may need additional D&C procedures if menorrhagia recurs.
  • 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 uterine artery embolization, the surgeon passes a catheter through the large artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with materials that 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 – This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
  • Endometrial ablation – This procedure involves 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 endometrial ablation, most women have much lighter periods. Pregnancy after endometrial ablation has many associated complications. If you have an endometrial ablation, the use of reliable or permanent contraception until menopause is recommended.
  • Endometrial resection – This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding. Pregnancy isn’t recommended after this procedure.
  • Hysterectomy –  Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. A hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.


References

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