Menorrhagia

Introduction

• Description: Menorrhagia—heavy menstrual flow—is generally divided into primary and secondary. Secondary is caused by (secondary to) some clinically identifiable cause; primary is caused by a disturbance in prostaglandin production. Menorrhagia is generally distinguished from acute vaginal bleeding (most often associated with pregnancy and pregnancy complications). Menorrhagia is classified as heavy menstrual bleeding under the terminology used for dysfunctional (abnormal) uterine bleeding.

• Prevalence: 10%–15% of women experience excessive menstrual flow; 5% of women between the ages of 30 and 49 years consult a clinician for evaluation of menorrhagia annually.

• Predominant Age: Reproductive age.

• Genetics: No genetic pattern.

Etiology and Pathogenesis

• Causes: Secondary—see Differential Diagnosis in the following section. Primary—overproduction or an imbalance in the relative ratios of uterine prostaglandins (prostaglandin E ₂ , prostaglandin I ₂ , and thromboxane A ₂ ). Some evidence suggests that patients with primary menorrhagia also have increased fibrinolysis, further enhancing a tendency to bleed.

• Risk Factors: Diabetes, obesity, or chronic anovulation (which places the patient at a higher risk for endometrial hyperplasia or malignancy), systemic disease, or metabolic disturbances associated with bleeding dyscrasias.

Signs and Symptoms

• Menstrual loss of greater than 80 mL, which may result in anemia

• Excessive soiling or numbers of menstrual hygiene products used (objective studies have shown a poor correlation with the actual measured blood loss)

• Anemia (in the absence of other causes of anemia, anemia is diagnostic for menstrual volumes of greater than 80 mL per cycle)

Diagnostic Approach

Differential Diagnosis

• Uterine leiomyomata (one-third of patients will have menorrhagia)

• Adenomyosis (40%–50% have menorrhagia)

• Endometrial or cervical polyp(s)

• Endometrial hypertrophy or hyperplasia

• Endometrial cancer

• Cervical lesions (including cancer)

• Infection (cervicitis, chronic endometritis)

• Intrauterine contraceptive device use

• Chronic anovulation

• Nongynecologic causes include blood dyscrasia or coagulopathy, hypothyroidism, leukemia, hepatic or renal disease, systemic lupus erythematosus, thyroid disease

• Benign or malignant hormone producing tumors of ovary (rare)

Associated Conditions: Anemia, toxic shock syndrome (prolonged tampon use).