Menorrhagia (Heavy Menstrual Bleeding)
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- The current preferred terminology for menorrhagia is “heavy menstrual bleeding” (HMB).
- HMB is an excessive amount (≥80 mL/cycle, compared with normal average of 30 to 60 mL/cycle) or periods lasting longer than 7 days.
- Clinically, HMB is an excessive menstrual blood loss which interferes with the woman’s physical, emotional, social, and material quality of life.
- Other patterns of AUB which may overlap with HMB include:
- Intermenstrual bleeding (IMB; previously metrorrhagia): bleeding between regular menses
- Polymenorrhea: menstrual cycle length <21 days
- HMB applies only to ovulatory menses and is a subcategory of “abnormal uterine bleeding” (AUB).
- A classification system called the PALM-COEIN was developed to describe AUB in women of reproductive age.
- It includes the structural causes (polyp, adenomyosis, leiomyoma [submucosal or other myoma], and malignancy and hyperplasia) and nonstructural causes (coagulopathy, ovulatory dysfunction, endometrial, Iatrogenic, and not yet classified).
- System affected: reproductive
- HMB affects >10 million American women each year or about one out of every five women (1).
- Puberty and the perimenopause typically are associated with AUB and are considered to be physiologic in these circumstances (2).
- Genital bleeding before puberty is not menstrual bleeding by definition and requires further evaluation.
- Due to immaturity of the hypothalamic-pituitary-ovarian axis, adolescents are at risk of irregular bleeding and HMB.
- Adolescents with HMB should be evaluated for possible bleeding disorders, especially von Willebrand disease (3)[C].
Bleeding in pregnancy is not menstrual bleeding by definition and requires further evaluation. Pregnancy test should be obtained as part of the evaluation of AUB.
Menopause is diagnosed after 12 months of amenorrhea in the absence of other causes and is typically preceded by irregular bleeding. All postmenopausal bleeding requires additional workup for malignancy.
Etiology and Pathophysiology
- No cause is identified in about 1/2 of patients.
- Bleeding disorders
- Von Willebrand disease
- ITP and other platelet disorders
- Factor deficiencies
- Medication side effect most commonly related to anticoagulants including warfarin
- Renal failure leading to uremic platelet dysfunction
- Cirrhosis leading to coagulopathy
- Uterine fibroids, typically submucosal
- Endometrial polyps
- Iatrogenic causes including copper intrauterine device (IUD)
- Pelvic inflammatory disease
- Some causes more typically presenting as irregular menstrual bleeding include:
- Polycystic ovarian syndrome (PCOS)
- Hypothalamic-pituitary dysfunction, often postmenarchal or during menopausal transition
- Endometrial or ovarian neoplasia
- Some forms of hormonal birth control
- HMB has been associated with increased production and sensitivity to prostaglandins.
- Combined oral contraceptives may prevent HMB, particularly when progesterone is dominant. Lower estrogen doses result in less menstrual bleeding.
- NSAIDs including ibuprofen inhibit prostaglandin production and result in decreased blood loss and pain during menses.
- Progesterone-only contraceptives may reduce overall blood loss but often result in irregular bleeding.
Commonly Associated Conditions
Iron deficiency anemia