Menorrhagia

What is Menorrhagia?

Abnormal uterine bleeding (AUB) is the term used for any irregularities in a woman’s normal menstrual cycle. Your menstrual cycle usually lasts an average of 29 days, though it can range from 23 to 39 days, with periods that last 2 to 7 days.

Two large medical organizations, the International Federation of Gynecology and Obstetrics and the American Congress of Obstetricians-Gynecologist, use a certain system to classify AUB as either having physical causes (structural) or due to other reasons (non-structural). They use something called the PALM-COEIN system.

Because of this system, old terms like menorrhagia (long or heavy periods), oligomenorrhea (periods more than 35 days apart), intermenstrual bleeding (bleeding between periods), and postmenopausal bleeding are less commonly used. It’s noteworthy that about 30% of uterus removal surgeries (hysterectomies) performed in the USA are due to heavy periods.

This article will talk about emergency situations of AUB in women of reproductive age, who are not pregnant, when the bleeding is heavy enough that it needs immediate treatment to prevent losing more blood.

What Causes Menorrhagia?

Menorrhagia, also known as abnormal bleeding from the womb, can be sorted into nine categories using the easy-to-remember acronym PALM-COEIN. This acronym helps doctors differentiate between structural (physical changes in the womb) and non-structural causes (related to body function and hormones):

* Polyp
* Adenomyosis
* Leiomyoma
* Malignancy and hyperplasia
* Coagulopathy
* Ovulatory dysfunction due to underactive or overactive thyroid, tumors causing excessive prolactin, or PCOS (Polycystic Ovary Syndrome)
* Endometrial
* Iatrogenic (caused by certain medical procedures or drugs like intrauterine devices (IUDs), chemotherapy drugs, and anticoagulants)
* Not yet classified

For best treatment results, it’s important for the doctor to identify the most probable cause behind the abnormal bleeding.

Risk Factors and Frequency for Menorrhagia

Abnormal uterine bleeding, formerly known as menorrhagia, is a common problem amongst women in the United States. It significantly affects a woman’s quality of life, work performance, and health care expenses. It is reported to affect 53 in every 1000 women each year. In fact, it’s one of the top reasons women visit gynecologists in clinics, with 20 to 30% of patients mentioning it as a concern each year.

Signs and Symptoms of Menorrhagia

For determining the cause of abnormal uterine bleeding (AUB), the health provider should thoroughly check the patient’s health history. This record should include thorough knowledge about the patient’s current bleeding, menstrual history, gynecological and obstetrical backgrounds, as well as medical and surgical histories. The doctor should also be informed about the patient’s current medication, sexual activities, and family history. For instance, women who need to change pads or tampons every three hours and observe blood clots likely have a substantial blood loss of at least 80mL. Medical experts cite that a significant number of women dealing with AUB might have some form of blood clotting disorder, the most common being von Willebrand disease.

Doctors can use a recognized clinical screening tool to determine if the patient requires further tests for blood clotting disorders. A positive screening would include:

Heavy menstrual bleeding from the first period (menarche)
Either of the following:
- Bleeding excessively after childbirth (postpartum hemorrhage)
- Bleeding related to a surgical procedure
- Bleeding related to dental work
Or two or more of the following:
- Experiencing unusual bruising twice a month
- Experiencing nosebleeds at least once or twice a month
- Frequent bleeding from the gums
- Having family members with bleeding symptoms

The initial physical examination should focus on detecting any life-threatening conditions that can occur due to acute blood loss, such as anemia or low blood volume (hypovolemia). It is also vital to identify the specific cause of the abrupt uterine bleeding. The doctor would perform a speculum examination to thoroughly check the genital tract and exclude the possibility of trauma or other causes of bleeding. A hand-on exam (or bimanual exam) to identify uterine abnormalities and swelling caused by benign uterine tumors (leiomyomas) or cervical abnormalities caused by growths (polyps) or cervical cancer is also necessary.

Testing for Menorrhagia

In order to decide the best course of treatment for a patient, doctors usually begin by doing some lab tests. These include a complete blood count (which checks the levels of different types of cells in your blood), identifying your blood type (needed in case you require a blood transfusion), and a pregnancy test.

Other valuable tests that provide important information about your health might include checking your thyroid-stimulating hormone levels (to see how well your thyroid is working), iron studies (to check for conditions like anemia), liver function tests, and tests for sexually transmitted diseases. If the doctor has reasons to suspect that your blood might not be clotting properly, they might also do tests for a condition called von Willebrand disease and other clotting disorders.

For certain conditions, an ultrasound scan of the pelvic area may be done. This can help doctors find any abnormal growths and check the size and shape of the uterus and the area around it, known as the adnexa.

If a woman is at risk of uterine cancer, cellular growth abnormalities (‘hyperplasia’), or growths called ‘polyps’, the doctor may recommend a procedure called an endometrial biopsy. This involves taking a small sample of tissue from inside the uterus to examine it more closely under a microscope.

Treatment Options for Menorrhagia

The first step in managing abnormal uterine bleeding (bleeding that’s more than normal or lasts longer than normal) is stabilizing the patient’s vital signs, including heart rate and blood pressure. If the patient is unstable, healthcare providers will ensure they have proper intravenous (IV) access for fluid and medicine administration, assess their breathing, and prepare for a possible blood transfusion.

In urgent cases, before surgical intervention, a tamponade, a medical device to stop bleeding, can be used. One example of this is the Bakri balloon which can be inserted into the uterus to stop the uterine bleeding. In some cases where a balloon is not available, gauze packing can be used as an alternative. If the bleeding cannot be managed by these means, surgery may be necessary.

The standard surgical procedure for patients whose condition is not stable and are bleeding heavily is a dilation and curettage (also known as ‘D&C’). This is a quick procedure that can generally control bleeding within an hour. It involves dilating (stretching) the cervix (the opening to the uterus) and removing (curetting) some of the lining of the uterus. However, D&C can only give temporary relief and won’t cure the underlying causes of abnormal uterine bleeding.

In a stable patient, treatment aims to manage the current bleeding and prevent future episodes. Hormonal therapy is typically the first line of treatment, with several options including oral contraceptive pills, IV estrogen, different types of progesterone, and tranexamic acid.

IV estrogen is the only method specifically approved by the FDA for acute uterine bleeding due to limited scientific studies.
It may stop bleeding in about 72% of patients within 8 hours, but there are some contraindications to its use, including a current diagnosis of breast cancer, past or present deep vein thrombosis, arterial thromboembolic disease, and liver dysfunction. After 24 hours, the patient should switch to oral contraceptives or progesterone to reduce unopposed estrogen exposure.

Oral contraceptive pills and oral progesterone are commonly used medications for acute uterine bleeding. These were found to stop bleeding within 3 days in up to 88% of women in one study. However, these do have contraindications as well, including being over the age of 35 and smoking, having hypertension, a history of deep vein thrombosis (DVT) or pulmonary embolism (PE), known thromboembolic disease, cerebrovascular disease, ischemic heart disease, migraines with aura, current or past breast cancer, and severe liver disease.

Under certain circumstances, surgical options, including D&C, endometrial ablation (a procedure where the lining of the uterus is destroyed to reduce heavy menstrual bleeding), uterine artery embolization (a minimally invasive treatment that blocks the blood vessels that supply the uterus to stop heavy, prolonged menstrual bleeding), and hysterectomy (surgery to remove the uterus) could be considered. These are used when medical therapies are contraindicated (not advisable) or do not work. The specific type of surgery used will depend on the individual patient’s condition and the cause of the abnormal bleeding.

This article has previously discussed the FIGO system for classifying AUB causes. But doctors also use another system, the PALM-COEIN classification, to identify nine possible causes for AUB. Let’s now also look at some other conditions that are important to rule out when diagnosing AUB in the emergency room. It’s interesting to note that the uterus is the only organ in which bleeding is a normal function. This can sometimes hide other causes of anemia, especially in women who are near menopause.

A regular menstrual cycle normally lasts between 4 to 9 days, and the amount of blood lost is usually under 80 mL. Some women may experience symptoms like cramping, mood changes, breast soreness, and water retention before their periods start. Both pregnancy and ectopic (outside the uterus) pregnancy can also lead to vaginal bleeding. For this reason, all women who could potentially be pregnant should take a pregnancy test as part of their examination.

What to expect with Menorrhagia

The chances of recovery from AUB, or abnormal uterine bleeding, heavily depend on the cause. The PALM-COEIN system is a classification method used to identify these causes. For premenopausal women, who experience sudden uterine bleeding, it’s often their quality of life that compels them to seek medical help. About 50% of women with abnormal uterine bleeding lose less than 40 milliliters of blood, meaning the impact on their day-to-day life is the main concern.

Using quality of life tests, it has been found that women with AUB generally score below 25 percentile when compared to other women of similar age. So, when doctors treat and manage these patients, they don’t only focus on physical health outcomes. They also consider the impact on the person’s quality of life. A popular tool for measuring this is the short-form 36 health survey. It’s used in about 63% of research studies relating to AUB.

Recently, a unique questionnaire was developed specifically for heavy menstrual bleeding. This tool helps validate patient-reported outcomes by covering a range of symptoms. This includes the amount of bleeding, social embarrassment, and anxiety about social interactions due to AUB.

Frequently asked questions

Menorrhagia is a term used to describe long or heavy periods.

Menorrhagia affects 53 in every 1000 women each year.

Signs and symptoms of Menorrhagia, which is a form of abnormal uterine bleeding (AUB), may include: - Needing to change pads or tampons every three hours or less - Observing blood clots during menstruation - Experiencing heavy menstrual bleeding from the first period (menarche) - Bleeding excessively after childbirth (postpartum hemorrhage) - Bleeding related to a surgical procedure - Bleeding related to dental work - Experiencing unusual bruising twice a month or more - Experiencing nosebleeds at least once or twice a month - Frequent bleeding from the gums - Having family members with bleeding symptoms It is important to note that Menorrhagia can be a symptom of an underlying condition, such as a blood clotting disorder like von Willebrand disease. If a person experiences any of these signs and symptoms, it is recommended to consult a healthcare provider for further evaluation and diagnosis.

Menorrhagia can be caused by various factors, including structural changes in the womb (such as polyps, adenomyosis, leiomyoma, malignancy, and hyperplasia), non-structural causes related to body function and hormones (such as coagulopathy, ovulatory dysfunction, endometrial issues, iatrogenic causes), and some cases that are not yet classified.

The doctor needs to rule out the following conditions when diagnosing Menorrhagia: 1. Structural causes of abnormal uterine bleeding (AUB) using the PALM-COEIN system. 2. Other causes of AUB that are non-structural using the PALM-COEIN system. 3. Uterine cancer. 4. Cellular growth abnormalities (hyperplasia). 5. Polyps. 6. Anemia. 7. Pregnancy. 8. Ectopic pregnancy.

The types of tests that may be needed to diagnose Menorrhagia (abnormal uterine bleeding) include: - Complete blood count (CBC) to check levels of different types of cells in the blood - Blood type identification in case a blood transfusion is required - Pregnancy test - Thyroid-stimulating hormone (TSH) levels to assess thyroid function - Iron studies to check for conditions like anemia - Liver function tests - Tests for sexually transmitted diseases - Tests for clotting disorders, such as von Willebrand disease - Ultrasound scan of the pelvic area to identify abnormal growths and assess the uterus and surrounding area - Endometrial biopsy to examine tissue from inside the uterus for cellular growth abnormalities, polyps, or uterine cancer.

Menorrhagia, or abnormal uterine bleeding, can be treated in various ways depending on the patient's condition. In stable patients, the first line of treatment is hormonal therapy, which includes options such as oral contraceptive pills, IV estrogen, different types of progesterone, and tranexamic acid. IV estrogen is specifically approved by the FDA for acute uterine bleeding and can stop bleeding in about 72% of patients within 8 hours. After 24 hours, the patient should switch to oral contraceptives or progesterone. Oral contraceptive pills and oral progesterone are commonly used medications that can stop bleeding within 3 days in up to 88% of women. However, these hormonal therapies have contraindications, such as age, smoking, hypertension, history of thromboembolic disease, and severe liver disease. In cases where medical therapies are not advisable or do not work, surgical options like D&C, endometrial ablation, uterine artery embolization, or hysterectomy may be considered. The choice of surgery depends on the individual patient's condition and the cause of the abnormal bleeding.

When treating Menorrhagia, there can be side effects associated with hormonal therapy, such as oral contraceptive pills and oral progesterone. These side effects include: - Contraindications for oral contraceptive pills: being over the age of 35 and smoking, having hypertension, a history of deep vein thrombosis (DVT) or pulmonary embolism (PE), known thromboembolic disease, cerebrovascular disease, ischemic heart disease, migraines with aura, current or past breast cancer, and severe liver disease. - Contraindications for IV estrogen: current diagnosis of breast cancer, past or present deep vein thrombosis, arterial thromboembolic disease, and liver dysfunction. - Switching to oral contraceptives or progesterone after 24 hours of IV estrogen use to reduce unopposed estrogen exposure. - Other surgical options, such as D&C, endometrial ablation, uterine artery embolization, and hysterectomy, may be considered when medical therapies are contraindicated or do not work. The specific type of surgery used will depend on the individual patient's condition and the cause of the abnormal bleeding.

The prognosis for menorrhagia, or heavy menstrual bleeding, heavily depends on the cause. Recovery rates vary depending on the underlying condition causing the abnormal uterine bleeding. However, it is important to note that about 50% of women with abnormal uterine bleeding lose less than 40 milliliters of blood, and their main concern is the impact on their day-to-day life.

You should see a gynecologist for Menorrhagia.

Dysfunctional Uterine Bleeding Menstrual Cycle Menstrual Disorders Vaginal Bleeding Women's Health