Menorrhagia is defined as the occurrence of excessive bleeding, with respect to quantity and duration, during regular menstruation.
Menorrhagia is clinically defined as more than 80 milliliters (mL) of blood loss during each period, or periods lasting more than 7 days. A normal period comes every 21-35 days, with an average of 25-80 mL of blood being lost during each cycle.
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The most common factors that are associated with menorrhagia include:
- Pregnancy (to be ruled out in all women who are sexually active and of reproductive age)
- Pelvic pain
- Pelvic diseases, such as fibroids or adenomyosis
- Sexually transmitted infections (STIs)
- Pelvic inflammatory disease
- Anovulatory conditions, especially polycystic ovarian syndrome (PCOS)
- Hormonal disturbances which prevent normal ovarian function
- Bleeding disorders, like a platelet deficiency
- Chronic illness of the kidneys or diabetes
- Treatment with hormones or anticoagulants
Signs of underlying disease
A physical examination may allow for the identification of conditions that cause or contribute to the menorrhagia. These signs will also show if there is obvious anemia as a result of severe blood loss, or if the bleeding is heavy enough to pose danger to the patient’s life.
Some of the common signs that healthcare professionals will look for during a physical examination include:
- Abnormal hair growth on the face or body
- Bleeding points under the skin, nails, or gums
- Thyroid enlargement or signs of thyroid disease
- Milky discharge from the nipples
The cause of menorrhagia is sought by a careful history of additional symptoms, a physical examination, as well as blood tests to evaluate hormonal levels, other possible contributing factors, the presence of a pelvic infection, or bleeding disorders.
Cultures may be taken if there is any suspicion of a pelvic infection. A pelvic ultrasound and other imaging procedures may be needed to confirm the diagnosis.
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The treatment of menorrhagia depends upon many factors, such as:
- Desire for childbearing
- Presence of pelvic diseases such as endometriosis, ovarian cysts, or fibroids
- Presence of pelvic infection
- The current health status of the woman
- How the menorrhagia affects the daily life of the individual
Treatment commonly starts with treating all contributing or causative medical conditions, such as bleeding disorders, thyroid disease, or hormonal imbalances.
If the treatment of these underlying conditions is not sufficient to reduce the bleeding and its associated symptoms, menorrhagia can also be treated with drugs including:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen
- Mefenamic acid, which is an NSAID that reduces menstrual bleeding
- Tranexamic acid can regulate menstrual bleeding without any hormonal intervention
- Birth control pills help to make periods regular, as well as reduce blood loss and the pain of periods
- Oral progesterone can be taken for 10 days each cycle to prime the uterus and prevent heavy bleeding
- A progesterone intrauterine device (IUD) can lighten menstrual blood flow; however, this treatment can cause cessation of periods in some women as long as the IUD is in place
- Iron supplements if blood counts are low
Several surgical options are also available to treat menorrhagia. Dilatation and curettage, for example, involves the scraping away of the uterus lining to check for a hormonal imbalance and reduce the endometrial thickness, as well as immediately reduce bleeding for the current cycle.
Fibroid surgery, which can involve either the removal of the fibroid or of the uterus, can also be performed. Notably, the decision to undergo fibroid surgery often depends on the patient's age and a desire to become pregnant in the future. Other fibroid surgeries include embolization of the uterine arteries to cut off the fibroid’s blood supply, thereby shrinking it, and ultrasound ablation or removal of the fibroid using ultrasound energy
Endometrial ablation and/or endometrial resection refers to various techniques to achieve permanent removal of the uterine lining without removing the uterus or ovaries. This procedure, which often lightens the period, is only suitable for women who are willing and able to practice reliable contraception until menopause, as the thinned-out uterine lining cannot support a pregnancy successfully.
A hysterectomy is a procedure in which the uterus is removed. This is a major procedure requiring hospitalization but completely ends periods and may be a last resort in intractable menorrhagia.