Background

Menorrhagia is a condition which causes very heavy or lengthy menstrual cycles. This condition can affect the daily activities and quality of life in all age of women. Menstrual bleeding cycle will last more than 7 days, or loss of blood is over 8 mL in every cycle in this disease. It can also lead to change the sanitary products for more than every 2 hours or more blood clots will pass over a quarter.  

Menorrhagia can occur due to hormonal imbalances, polyps, uterine fibroids, adenomyosis, certain medications, pelvic inflammatory disease, and blood clotting diseases.  

Epidemiology

Prevalence: 

Menorrhagia is a prevalent gynecological condition which affects many women during reproductive phase. About 9 % to 14 % of women have this disease in the reproductive age. 

Age Distribution: 

Menorrhagia affects the women in the age of 30 to 49 years. Adolescents and women who are having menopause may have abnormal uterine bleeding.  

Impact on Quality of Life: 

Menorrhagia can affect the physical, emotional, and social life. The heavy menstrual bleeding linked with menorrhagia can lead to anemia and fatigue. 

Underreporting: 

Menorrhagia is underreported. Many women consider a heavy menstrual bleeding to a normal menstrual cycle. Some are hesitant to discuss it with healthcare providers. 

Anatomy

Pathophysiology

Endometrial factors: 

Endometrial polyps are growths in the uterus that lead to excessive or prolonged bleeding. Endometrial hyperplasia is an increased thickness of the uterine lining that lead to excessive bleeding.  

Coagulation Disorders: 

Von Willebrand disease is a clotting related genetic disease that increases the excessive menstrual bleeding. Platelet function diseases affect platelets which are responsible for clotting. This can lead to excessive bleeding. 

Infection and inflammation: 

Pelvic inflammatory disease (PID) causes infection in the reproductive organ and lead to abnormal bleeding. Chronic endometritis causes inflammation in the endometrium, which causes excessive bleeding. 

Iatrogenic Causes: 

Specific medications like anticoagulants can lead to excessive menstrual bleeding. 

Etiology

Hormonal Imbalances: 

Anovulation: A high levels of estrogen than progesterone may lead to irregular or deficient ovulation. This can disrupt the normal balance of hormone and lead to excessive or prolonged menstrual bleeding.  

Uterine Structural Abnormalities: 

Uterine Fibroids: Non-cancerous tumors in uterus can lead to enlarge abdominal cavity and excessive menstrual bleeding. 

Adenomyosis: It causes endometrial tissue to enter the uterine muscle wall and lead to excessive bleeding. 

Genetics

Prognostic Factors

Identification and management of the particular cause of menorrhagia play an important to determine the prognosis. Disease like uterine fibroids, endometrial polyps, and adenomyosis need various ways of treatment. Age of individual can affect the prognosis. Imbalances in hormone and abnormalities in structure in the young women are common cause of this disease. Endometrial cancer causes this condition in older women. 

Desire of a women for pregnancy may affect the prognosis. Surgical treatment may affect the fertility and should be considered in the management of disease. The effectiveness of particular treatment will have some impact on prognosis. Hormonal therapy, surgical treatment, and other medical management can lead to different improvement. Conditions like bleeding disease or chronic conditions can affect the prognosis of menorrhagia. 

Clinical History

Adolescents (12 years to 18 years): 

• Clinical presentation: Irregular menstrual cycles are common in adolescents. It will take time to get into regular pattern. Menorrhagia may lead to excessive and prolonged bleeding which affect the normal daily activity. 
• Associated comorbidities: Imbalance in hormones during puberty 
• Acuity of presentation: Adolescents have not any long history of menstrual cycles. Any disruption in the daily life activity because of the excessive bleeding need medical attention. 

Reproductive Age (18 years to 45 years): 

• Clinical presentation: Excessive bleeding for more than 7 days and need to change sanitary products frequently are the symptoms.  
• Associated comorbidities: Uterine fibroids, endometrial polyps, adenomyosis, or imbalance in hormones, pregnancy related complications like ectopic pregnancy or miscarriage can be considered. 
• Acuity of presentation: Changes in the daily activity and decreasing the quality of life need medical attention. 

Perimenopausal (Late 40 years to early 50 years): 

• Clinical Presentation: Any changes in the menstrual cycle patterns, like increased variability in the length of the cycle or excessive bleeding along with irregular cycles, are symptoms.  
• Associated comorbidities: Uterine fibroids, endometrial atrophy, and adenomyosis can be considered.  Changes in menstrual patterns, with increased variability in cycle length. Heavy menstrual bleeding with irregular cycles. 
• Acuity of Presentation: Any sudden changes in the menstrual cycle pattern need medical attention. 

Physical Examination

General Examination will check for the overall health, vital signs, and general health status of patient. It also assesses for any symptoms of anemia like fatigue, weakness, or pallor. 

Abdominal Examination will check for abdominal palpitation for any lumps or soreness which can lead to pelvic disease. It also checks for size and form of uterus and diseases like adenomyosis or fibroids which can lead to expansion. 

Pelvic Examination will check for evaluation of menorrhagia. It includes speculum, bimanual, and digital examination. Speculum examination will see the cervix and exclude any abnormality like cervical or polyps lesions. Bimanual and digital examination will assess the shape, size and mobility of uterus and check for any pelvic tenderness or masses. 

Cervical and vaginal cultures are collected to identify the presence of pathogens in case of infection. 

Rectovaginal Examination is performed to check the posterior part of uterus for tenderness or masses. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Hormonal causes like dysfunctional uterine bleeding (DUB) and polycystic ovary syndrome (PCOS) 

Structural causes like uterine fibroids (leiomyomas), endometrial polyps, adenomyosis 

Endometrial causes like endometrial hyperplasia, endometrial cancer 

Infectious causes pelvic inflammatory disease 

Coagulation disease like Von Willebrand disease, platelet function disease 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Medical treatments: 

Non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen can reduce the menstrual bleeding and pain. Hormonal therapy like combined oral contraceptives (COCs) like birth control medication, which contain progastrin and estrogen, can regular menstrual cycle and reduce bleeding. Medications, injection or intrauterine devices (IUDs) which contain progestin can reduce the heavy bleeding. Levonorgestrel releasing intrauterine system (LNG-IUS) releases progestin hormone in uterus to reduce the bleeding. 

Gonadotropin releasing hormone (GnRH) agonists can activate menopausal state and reduce bleeding. It is used for short term because of the side effects. Antifibrinolytic agents like tranexamic acid can reduce the bleeding by creating blood clotting. 

Surgical treatments: 

Endometrial Ablation is a minimally invasive technique. It is used to eliminate menstrual cycle by destroying uterine lining. A small particles are inserted into the blood vessels of uterus to block the flow to fibroid and reduce bleeding in uterine fibroid embolization (UFE) or uterine artery embolization procedure. Uterine fibroids are removed, and uterus is saved in myomectomy. Uterus is surgically removed in hysterectomy. When the other treatment are failed, or there is no concern of fertility, then this treatment is performed,  

Adjunctive treatments: 

Iron supplements are given in anemia of chronic heavy bleeding. Lifestyle changes like regular exercise, management of stress, and a healthy and balanced diet can reduce symptoms. Alternative treatments like acupuncture or herbal therapies are used to reduce the symptoms of menorrhagia. 

Treatment of Underlying Conditions: 

Treat any conditions like imbalance in hormone, coagulation disease, abnormality in structure can reduce menorrhagia.  

Follow-Up and Monitoring: 

Regular follow-up and monitor the patients to check the effectiveness of treatment, monitor side effects are necessary. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-a-non-pharmacological-approach-to-treat-menorrhagia

Lifestyle Modifications: 

A diet rich in vitamin C, iron like lean meats, leafy vegetables, fortified cereals can manage anemia linked to menorrhagia. Regular exercises can regulate menstrual cycles and reduce the excessive bleeding.  

Alternative Therapies: 

Acupuncture is a traditional Chinese techniques. A small needle is inserted into body sites to reduce symptoms of menorrhagia. Herbal remedies like vitex, ginger, and turmeric have anti-inflammatory effects and can regulate the hormone.  

Dietary and Lifestyle Changes to balance hormones: 

Achieve and maintain a healthy weight can regulate the hormone and menstrual cycles. Meditation, relaxation exercise, and mindfulness can reduce the stress and regulate levels of hormone.  

Use of Menstrual Products: 

Menstrual cups are used instead of traditional tampons or pads. It is useful during the heavy flow. It does not treat menorrhagia directly but provide comfort. 

Role of NSAIDs to treat menorrhagia

NSAIDs can play a necessary role to treat menorrhagia. It manages the pain and reduces the bleeding. They have anti-inflammatory property which can lower the inflammation in uterine lining. They inhibit the production of prostaglandins. It play an important role in the contraction of uterine and regulate the blood flow to uterus. NSAIDs increase the contraction of uterine, reduce levels of prostaglandin, and reduce the bleeding. 

Naproxen:  

It provides relief to mid to severe discomfort. It inhibits production of prostaglandins by cyclooxygenase and reduces the inflammation and discomfort. 

Role of Combination Oral contraceptives to treat menorrhagia

Combination oral contraceptives contain estrogen and progestin. They regulate menstrual cycle, reduce thickness of endometrial lining, and stabilize the fluctuations in hormone. The progestin stabilizes the endometrial lining and reduce the menstrual blood flow.  

Dienogest/estradiol valerate is used with oral contraceptives to treat excessive bleeding, which is not detected in uterine problems. 

Role of progestins to treat menorrhagia

Progestins which are synthesized play an important role to treat this disease. Progestins have many actions which are able to treat menorrhagia. It stabilizes the endometrial lining in uterus and reduce the tissue amount which are needed during menstruation. It reduces bleeding and suppress ovulation and create more stable environment of hormone.  

Medroxyprogesterone Acetate (MPA) and norethindrone are synthetic progestin. They are used to treat menorrhagia. They are available in various forms, like oral tablets and injections.  

Levonorgestrel-Releasing Intrauterine System (LNG-IUS): It is a contraceptive device which releases a small amount of levonorgestrel into the uterus directly. It reduces bleeding and manage the menorrhagia.  

Role of Gonadotropin-releasing hormone agonists to treat menorrhagia

GnRh agonists inhibit the peak of gonadotropins that is followed by downregulation and inhibition of pituitary gland. It leads to temporary menopause. This reduces or stop bleeding. The inhibit the production of progesterone and estrogen.  

Leuprolide Acetate (Lupron): It is a GnRH agonist and available in different forms like monthly injections, subcutaneous implant. It causes an elevated level in gonadotropin and lead to downregulation, and inhibit the secretion of gonadotropin. 

Goserelin (Zoladex): It is a GnRH agonists and available in subcutaneous implant. It has a same action as Lupron. 

Role of Androgens to treat menorrhagia

Danazol: 

It has a strong antigonadotrophic and mild androgenic effect. It is a synthetic steroid analog. It regulates the bleeding and causes amenorrhea in 3 months.  

Role of Arginine vasopressin derivatives to treat menorrhagia

Desmopressin (DDAVP):  

It is used to treat menorrhagia linked to Von Willebrand disease. It is available in different forms like oral, intranasal, and intravenous. 

use-of-intervention-with-a-procedure-to-treat-menorrhagia

Endometrial Ablation: 

It includes the destruction or removal of uterine lining to lower the bleeding. Different methods like thermal ablation, radiofrequency ablation, cryoablation, or microwave ablation can be used. Women who have excessive bleeding and not expected any pregnancy in future can go for this procedure. Examples: NovaSure, Thermachoice, Minerva, and others. 

Uterine Artery Embolization (UAE): 

UAE is a minimally invasive procedure. It reduces the bleeding by prevent the blood flow o fibroid and other abnormality in tissue by inserting small particles into uterine blood arteries. Women who have symptomatic uterine fibroids which can cause menorrhagia can go for this procedure.  

Myomectomy: 

It includes a surgical removal of uterine fibroids and preserve the uterus. It is performed by different methos like laparoscopic myomectomy, abdominal myomectomy, and hysteroscopic myomectomy. Women who have menorrhagia because of the uterine fibroids can go for this procedure.  

Hysterectomy: 

It is a medical procedure where uterus and cervix are removed. It eliminates menstrual bleeding. It is performed vaginally, abdominally, or laparoscopically. Women who have severe bleeding and completed with pregnancy or have condition which need the uterus removal can go for this procedure.  

Dilation and Curettage (D&C): 

D&C includes dilating cervix and scraping the uterus lining. It is used for diagnosis or to manage acute and severe bleeding. It is not a first line treatment but consider in specific situations.  

Hysteroscopy with Resection or Polypectomy: 

The uterus is punctured with a small tube which has camera. It is used to remove polyps or remove abnormal tissue in menorrhagia. Women who have menorrhagia because of uterine polyps or other abnormality can opt for this procedure.  

Laparoscopic Ovarian Diathermy (LOD): 

LOD is used to treat menorrhagia linked with PCOS. It includes cauterizing ovarian tissue to promote ovulation and regulate menstrual cycle. Women who have menorrhagia linked with anovulation and PCOS can go for this procedure.  

use-of-phases-to-manage-menorrhagia

Menorrhagia affects the menstrual cycle of women. It causes pain and inflammation. It is diagnosed by a comprehensive assessment which include medical history, physical examination and procedures like blood testing and ultrasound scan. Medical treatment like NSAIDs, antifibrinolytic agents and hormonal therapy can reduce the bleeding and symptoms.  

Non-pharmacological treatment like dietary supplements, lifestyle changes, and alternative therapy can reduce the symptoms of menorrhagia. Intervention procedures like removal of fibroids or polyps by hysteroscopy, myomectomy, UAE, and endometrial ablation can also be performed. 

Regular follow up and monitor the patient is necessary to treat menorrhagia. Long term management and prevention of disease include continue treatment to maintain the control of symptoms and recurrence. This includes lifestyle changes, hormonal therapy, monitoring to know any changes in menstrual cycles.  

Medication

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References

https://www.ncbi.nlm.nih.gov/books/NBK536910/