Heavy Menstrual Bleeding (Menorrhagia): Causes Diagnosis Treatment by NJE

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Heavy Menstrual Bleeding (Menorrhagia): Abnormal uterine bleeding (AUB) is a broad term for variations in normal menses. Normal duration of menstrual flow is 5 days; normal menstrual cycle is 21 to 35 days. Heavy menstrual bleeding, or menorrhagia, is a large volume of menstrual blood loss (i.e., > 80 ml per cycle). Bleeding may also be prolonged, intermenstrual, frequent, and irregular. This language replaces prior terms such as metrorrhagia, polymenorrhea, or oligomenorrhea.

PALM-COEIN classification of abnormal uterine bleeding was adopted in 2011 to standardize terminology and reflect aetiology: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not yet classified. AUB-P would refer to abnormal uterine bleeding due to polyps.

INCIDENCE: 10% to 15% of reproductive-aged  women; 30% of outpatient office visits; 70% of all gynecologic consults

PEAK INCIDENCE: Reproductive-aged women, ages 13 to 50

PREVALENCE: 9% to 14% of all women

PREDOMINANT SEX AND AGE: Female; peak in adolescence and perimenopausal periods

GENETICS: Hereditary coagulopathy (most commonly Von Willebrand disease, platelet dysfunction disorders) in 20% of women with heavy menstrual bleeding

RISK FACTORS: Genetic predisposition, anticoagulation treatment, obesity, endocrinopathies, autoimmune disease, liver disease, renal disease

PHYSICAL FINDINGS & CLINICAL PRESENTATION

• History: age, age at menarche or menopause, menstrual bleeding patterns, severity of bleeding, pain, underlying medical conditions, surgical history, medications, family history, hirsutism, acne, symptoms of thyroid dysfunction or other endocrinopathy

○ If heavy bleeding since menarche, screen for signs and symptoms of hemostatic disorder, including postpartum haemorrhage, surgery-related bleeding, bleeding from dental work, easy bruising, epistaxis, and frequent gum bleeding

• Physical exam: weight, hirsutism, acne, thy￾roid nodules, signs of insulin resistance (acanthosis nigricans), signs of bleeding disorder (petechiae, ecchymoses, pallor, swollen joints), pelvic examination including external, speculum, and bimanual exam of uterus

Causes of Heavy Menstrual Bleeding (Menorrhagia)

• Pregnancy/miscarriage

• Endometrial polyps

• Adenomyosis

• Uterine leiomyoma

• Endometrial hyperplasia or carcinoma

• Coagulopathy, inherited or acquired

• Ovulatory dysfunction, most likely PCOS

• Endometrial

• Iatrogenic

Diagnosis of Heavy Menstrual Bleeding (Menorrhagia)

DIFFERENTIAL DIAGNOSIS

Pregnancy, sexually transmitted infection, polycystic ovary syndrome (PCOS), thyroid dysfunction, anovulation due to immature hypothalamic-pituitary-ovarian axis or perimenopausal transition, uterine pathology including endometrial hyperplasia or carcinoma, leiomyoma, adenomyosis, or endometrial polyp, coagulopathy, iatrogenic due to medications including oral contraceptives or anticoagulants (warfarin), nonuterine bleeding (urinary, gastrointestinal, vaginal, or cervical source)

WORKUP

• History

• Physical exam

• Laboratory, pathology, and imaging studies to determine aetiology

LABORATORY TESTS

• Pregnancy test

• Complete blood count (CBC)

• Thyroid-stimulating hormone (TSH)

• Chlamydia trachomatis testing if high risk

• Pap smear if indicated

• Targeted screening for bleeding disorders

• Endometrial sampling by endometrial biopsy or hysteroscopic sampling for women >45 yr or <45 yr with history of unopposed estrogen (PCOS, obesity), failed medical management, or persistent abnormal bleeding

• Iron studies if anaemia is suspected

IMAGING STUDIES

• Pelvic ultrasound, transabdominal and transvaginal

• Sonohysterography or hysteroscopy if ultrasound is not adequate or further evaluation of the cavity is required

• MRI if needed for surgical planning or further evaluation of structural abnormality

Treatment of Heavy Menstrual Bleeding (Menorrhagia)

Surgical Management of Heavy Menstrual Bleeding (Menorrhagia)

• Dilation and curettage

• Hysteroscopic resection of uterine pathology including endometrial polyps and submucosal leiomyoma

• Myomectomy

• Endometrial ablation

• Uterine artery embolization

• Hysterectomy

Acute General Management of Heavy Menstrual Bleeding (Menorrhagia)

• Acute severe bleeding may be managed medically with oral progestins, combined oral contraceptive pills, IV estrogen, tranexamic acid, and/or blood transfusion as indicated. Surgical management includes dilation and curettage, uterine artery embolization, or hysterectomy.

Chronic Management of Heavy Menstrual Bleeding (Menorrhagia)

• Combined hormonal contraceptives (pill, transdermal patch, vaginal ring) in a cyclic or continuous regimen

• Progesterone intrauterine device: high degree of efficacy

• Oral or injected progesterone

• Gonadotropin-releasing hormone agonist

• Nonsteroidal anti-inflammatory drugs

• Tranexamic acid, aminocaproic acid

• Danazol (significant side-effect profile requires justification for use; this is rare)

• Surgery for anatomic causes, including polypectomy or myomectomy

• Uterine artery embolization for leiomyomatous uterus

• Endometrial ablation or hysterectomy if completed childbearing

• Replacement of or treatment for any abnormal bleeding factors.

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