Description

• Menorrhagia is a form of abnormal uterine bleeding (AUB) and describes a range of symptoms from heavy, prolonged or intermenstrual bleeding (1).
• It is defined as uterine bleeding of abnormal quantity, duration, and schedule in nonpregnant women of reproductive age, beyond menarche lasting for at least 6 months.
• The research standard for heavy menstrual bleeding (HMB) is >80 mL of blood lost per cycle. Clinically, menstrual blood loss is subjective, and abnormal is defined as a volume which interferes with the patient’s physical, social, emotional, and/or material quality of life.

Epidemiology

AUB is a common complaint with a prevalence of 3–30% and is one of the leading causes of outpatient gynecological visits. The prevalence varies with age and is higher in adolescence and in the 5th decade. It is linked to decreased quality of life and increased health care costs.

Etiology and Pathophysiology

• The pathophysiology of AUB is as diverse as the classification of the disease. More research needs to be done to elaborate the many causes of this condition.
• Any process that interferes with normal hemostatic, endocrine, or paracrine functions of the endometrium or interferes with myometrial contractility can cause AUB.
• It can be caused by structural issues such as the PALM acronym: polyp (AUB-P), adenomyosis (AUB-A), leiomyoma (AUB-L), malignancy/hyperplasia (AUB-M)
• Polyps are abnormal outgrowths of hypertrophied endometrial tissue, which is postulated to occur due to estrogen stimulation.
• Adenomyosis may affect normal myometrial contraction and cause AUB (3).
• Leiomyomas are benign myometrial neoplasms thought to form as a result of chromosomal abnormalities and grow in the presence of estrogen and progesterone.
• Excess estrogen can promote endometrial tumorigenesis (3).
• It can also be caused by nonstructural causes which include the COIEN acronym: coagulopathy (AUB-C), ovulatory (AUB-O), endometrial (AUB-E), iatrogenic (AUB-I), not yet classified (AUB-N).
• Ovulatory dysfunction is associated with a thick stratum functionalis caused by excessive estrogen stimulation of the endometrium. Endometrial shedding tends to be noncyclical with irregular bleeding noted.

Pediatric Considerations
Due to immaturity of the hypothalamic-pituitary-ovarian axis, adolescents are at risk of irregular and heavy menstrual bleeding. Of note, adolescents with heavy bleeding should be evaluated for possible bleeding disorders, especially von Willebrand disease and qualitative platelet dysfunction.

General Prevention

• Combined oral contraceptives may prevent HMB, particularly when progesterone is dominant. Lower estrogen doses result in less menstrual bleeding.
• Progesterone-only contraceptives may reduce overall blood loss but often result in irregular bleeding.