Menorrhagia

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Menorrhagia is menstrual blood loss which interferes with a woman's physical, emotional, social, and material quality of life, and which can occur alone or in combination with other symptoms. Any intervention should aim to improve her quality of life. Research studies usually take menorrhagia to be a monthly menstrual blood loss in excess of 80 ml.

The average menstrual cycle has a blood loss for 7 days of a cycle of between 21 and 35 days. The usual shorthand for this is:

K = 7/21-35 in which K represents menstrual cycle, 7 is the duration of bleeding and 21-35 represents the length of the cycle.

Menstrual loss is heaviest for the first few days and becomes much lighter, tailing off towards the end.

Other definitions include:

  • Metrorrhagia - flow at irregular intervals.
  • Menometrorrhagia - frequent and excessive flow.
  • Polymenorrhoea - bleeding at intervals of less than 21 days.
  • Dysfunctional uterine bleeding (DUB) - abnormal uterine bleeding without any obvious structural or systemic pathology.[1] It usually presents as menorrhagia. The diagnosis of DUB can only be made once all other causes for abnormal, or heavy, uterine bleeding have been excluded.
  • Dysmenorrhoea - pain with menstruation.

The average menstrual blood loss is about 35-40 ml. Some researchers have found that no more than 10% of women who complain of heavy menstruation have blood loss in excess of 80 ml. Menorrhagia is very subjective; a more practical definition may be that it is menstrual loss that is greater than the woman feels she can reasonably manage. The National Institute for Health and Care Excellence (NICE) defines heavy menstrual loss as excessive blood loss that interferes with a woman's physical, social, emotional and/or quality of life.[2]

Menorrhagia is related to increased limitations in physical activities and limitations in social and leisure activities.[3]

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Menorrhagia is a very common complaint:

  • 33% of women describe their periods as heavy.
  • The perception of what is heavy menstrual bleeding is subjective and 30% of women consider their bleeding excessive.[4] However only half of these women fit the clinical criteria of greater than 80 mls of blood loss per cycle.
  • DUB is more common around the menarche and perimenopause.
  • 1 in 20 women aged 30 to 49 years consult their GP each year for heavy periods and menstrual disorders.[5]
  • Each year a sum of around £7 million is spent in the UK on prescriptions in primary care to treat menorrhagia.
  • It is the second most common gynaecological condition to be referred to hospital, accounting for around 12% of all gynaecological referrals.[6] 
  • 40-60% of those who complain of excessive bleeding have no pathology and this is called dysfunctional uterine bleeding (DUB).
  • 20% of cases are associated with anovulatory cycles and these are most common at the extremes of reproductive life.
  • Local causes include:
  • Systemic disease can include hypothyroidism, liver or kidney failure, obesity and bleeding disorders - eg, von Willebrands's disease.
  • An intrauterine contraceptive device (IUCD) or anticoagulant treatment can increase menstrual flow.

See separate article Gynaecological History and Examination.

  • Note the total duration of bleeding and how much of that time it is heavy. Over 90% of menstrual loss occurs in the first 3 days and there is no correlation with the duration of loss and the total volume. Pictorial blood loss assessment charts may be useful.
  • Note the length of the cycle, ie the duration from the start of one period to the start of the next.
  • If the patient has to wear tampons and towels simultaneously, flow is heavy.
  • The passage of clots represents heavy flow. Clots may be painful as they pass through the cervix.
  • Ask about other associated menstrual problems - for example, premenstrual syndrome, intermenstrual bleeding (IMB), postcoital bleeding (PCB), dyspareunia and pelvic pain.
  • Ask about contraception and intentions with regard to further children, as this may affect management.
  • Ask about any symptoms to suggest anaemia.
  • Ascertain the effect on personal life, including any time off work.
  • Ask about past medical problems, including clotting disorders, thyroid status and gynaecological history.
  • Ask about easy bruising or bleeding gums.

Examination

Clinical examination should be undertaken to assess for any anaemia and also to rule out potential organic causes of menorrhagia.

  • Note general appearance and BMI. Body fat is very important in relation to metabolism of steroid hormones.
  • Note any signs suggestive of endocrine abnormality (hirsutism, acne) or bruising.
  • Look at the tongue for pallor and the nails for koilonychia.
  • Examination of the abdomen always precedes pelvic examination; otherwise, large pelvic masses can be missed.
  • Ascertain that the cervical smear is up-to-date.
  • Inspect the cervix and take swabs if clinically indicated.
  • Perform a bimanual examination. Abnormalities may include a bulky or grossly enlarged uterus, fixation of the uterus or tenderness.
  • Women can be asked to complete a pictorial representation to assess the volume of blood loss.
  • FBC is important. Every woman presenting with heavy menstrual bleeding should have FBC taken. The most common cause of iron deficiency anaemia in women is menorrhagia.
  • Tests for endocrine abnormalities, including TFTs should be performed only if there is clinical suspicion.
  • Assessment of bleeding disorders is only indicated if there is clinical suspicion.

If appropriate, you should refer the patient for an endometrial biopsy to exclude endometrial cancer or atypical hyperplasia. Indications for a biopsy include:

  • Persistent intermenstrual bleeding.
  • Symptoms that have not improved with medical management.
  • Women aged over 45 years with heavy menstrual bleeding.
  • Women with a history to suggest endometrial pathology.
  • If an abnormality is suspected after physical examination (apart from fibroids <3 cm in diameter).
  • Women with risk factors for endometrial cancer or hyperplasia.

Ultrasound (ideally transvaginal) is the first-line diagnostic tool for identifying structural abnormalities - eg, fibroids. An endometrial thickness of <12 mm is normal in premenopausal women. In addition, hysteroscopy can be used to assess the endometrial cavity.

Any woman referred to specialist care should be given information before her outpatient appointment. NICE has information for patients - available from the link below.

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Not everyone needs referral to secondary care.[2] If history and FBC are reassuring, drug treatment should be considered, if required. Medical treatment can be instituted in primary care. Patients are referred to exclude sinister pathology and when treatment in primary care has failed.

The main aims of treatment are to improve symptoms and also quality of life. Women should be advised on advantages and disadvantages of treatments and should also receive written information.

Pharmacological

When a first pharmaceutical treatment has proved ineffective then a second pharmaceutical treatment should be considered rather than immediate referral to surgery. If there is iron deficiency it should be corrected with oral iron.

First-line treatment
This is the levonorgestrel-releasing intrauterine system (IUS) - Mirena®. This is long-term treatment and should be left in situ for at least 12 months.[2]

  • One recent study has shown that women with menorrhagia reported more improvement in bleeding and quality of life with the levonorgestrel-releasing IUS than with other treatments available in primary care. In addition, they were more likely to continue with this treatment.[7]
  • However, the rate of discontinuation of Mirena® treatment has been shown to be relatively high - 16% at 12 months and 28% by 2 years.[5]

Second-line treatment
This includes tranexamic acid, mefenamic acid or the combined oral contraceptive pill (COCP):

  • Mefenamic acid works by inhibiting prostaglandin synthesis. It reduces menstrual loss by around 25% in three quarters of women and is better tolerated than tranexamic acid.
  • Tranexamic acid is a plasminogen-activator inhibitor. It inhibits the dissolution of thrombosis that leads to menstrual flow. It can reduce flow by up to 50%.[8] It is most effective at reducing menstrual loss associated with IUCDs, fibroids and bleeding diathesis. Other non-steroidal anti-inflammatory drugs (NSAIDs) may also be used. Side-effects include nausea, vomiting and diarrhoea. If there is disturbance in colour vision then it should be discontinued.
  • The COCP suppresses production of gonadotrophins and reduces menstrual blood loss by around 50%. It can improve dysmenorrhoea, lighten periods, regulate the cycle, improve premenstrual symptoms, reduce the risk of PID and protect the ovaries and endometrium against cancer.

Third-line treatment
This is with norethisterone.

  • The dose is 15 mg daily, from day 5 to 26 (or injected long-acting progestogens). This can result in a significant reduction in menstrual blood loss, although women tend to find the treatment less acceptable than intrauterine levonorgestrel. This regimen of progestogen may have a role in the short-term treatment of menorrhagia.
  • However, there are very limited data regarding the use of progestogens and of oestrogens and progestogens in combination in the treatment of irregular menstrual bleeding associated with anovulation. There is still no consensus about which regimens are the most effective.[9]

In secondary care 3-4 months of a gonadotrophin-releasing hormone (GnRH) analogue may be offered before hysterectomy or myomectomy, where the uterus is enlarged or distorted by fibroids. It is also a reasonable choice of therapy if other methods are contra-indicated - but 'add-back' hormone therapy will be needed if continued for >6 months.

In the acute situation, a bleeding episode may be so disabling for the woman that treatment with high-dose norethisterone (30 mg daily) needs to be used. This is continued until bleeding is controlled, but is then tailed off.

Surgical options

The choice of treatment will depend on both the uterine size and the patient's desire to retain her uterus:

Endometrial ablation
This is the recommended first-line treatment if the uterus is <10 weeks of gestation on palpation. It involves removing the full thickness of the endometrium together with the superficial myometrium, and the basal glands thought to be the focus of endometrial growth. It retains the uterus.

  • Endometrial ablation is contra-indicated in women with large fibroids or suspected malignancy and in those who have not completed their family.
  • There are various types of endometrial ablation:
    • Impedance-controlled bipolar radiofrequency ablation: a bipolar radiofrequency electrode is placed through the cervix and radiofrequency energy is delivered to the uterus.
    • Balloon thermal ablation: a balloon is inserted through the cervix to the endometrial cavity, inflated with a pressurised solution and then heated to destroy the endometrium.
    • Microwave ablation: a microwave probe is inserted into the uterine cavity to heat the endometrium, and moved side-to-side to destroy it.
    • Free fluid thermal ablation: heated saline is used to destroy the endometrium.
    • Rollerball ablation: a current is passed through a rollerball electrode which is moved around the endometrium.
    • Transcervical resection of the endometrium: small fibroids are removed using a cutting loop.
  • Unwanted outcomes of ablation include vaginal discharge; increased period pain (even if there is no further bleeding); the need for additional surgery; infection; perforation (very rare). NB: contraception after endometrial ablation is still advised even though fertility is usually not retained.

Uterine artery embolisation or hysteroscopic myomectomy
If the uterus is >10 weeks in size, and the woman wishes to retain her uterus, treatment options are uterine artery embolisation or hysteroscopic myomectomy.

Hysterectomy
If the patient does not wish to retain the uterus, then treatment is with hysterectomy - first consider vaginal, then abdominal with conservation of ovaries, if appropriate. Healthy ovaries should not be removed.

  • Hysterectomy is not first-line surgical management for DUB. Only consider when:
    • Other treatments have failed, are contra-indicated or declined.
    • There is desire for amenorrhoea.
    • The woman is fully informed and requests it.
    • There is no desire to retain the uterus and fertility.
  • Unwanted outcomes of hysterectomy include infection; intraoperative haemorrhage; damage to other organs, such as urinary tract and bowel; urinary dysfunction; thrombosis; menopausal-like symptoms if the ovaries are removed.

Further reading & references

  1. Pitkin J; Dysfunctional uterine bleeding. BMJ. 2007 May 26;334(7603):1110-1.
  2. Heavy menstrual bleeding; NICE Clinical Guideline (January 2007)
  3. Lukes AS, Baker J, Eder S, et al; Daily menstrual blood loss and quality of life in women with heavy menstrual bleeding. Womens Health (Lond Engl). 2012 Sep;8(5):503-11. doi: 10.2217/whe.12.36.
  4. Market Opinion and Research International, Women's Health in 1990; Research conducted on behalf of Parke Davies Research Laboratories, Cambridge: MORI, 1990
  5. Middleton LJ, Champaneria R, Daniels JP, et al; Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine BMJ. 2010 Aug 16;341:c3929. doi: 10.1136/bmj.c3929.
  6. Lethaby AE, Cooke I, Rees M; Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database of Systematic Reviews 2007 Issue 2.
  7. Gupta J, Kai J, Middleton L, et al; Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med. 2013 Jan 10;368(2):128-37. doi: 10.1056/NEJMoa1204724.
  8. Naoulou B, Tsai MC; Efficacy of tranexamic acid in the treatment of idiopathic and non-functional heavy menstrual bleeding: a systematic review. Acta Obstet Gynecol Scand. 2012 May;91(5):529-37. doi: 10.1111/j.1600-0412.2012.01361.x. Epub 2012 Feb 24.
  9. Hickey M, Higham JM, Fraser I; Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev. 2012 Sep 12;9:CD001895. doi: 10.1002/14651858.CD001895.pub3.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Hayley Willacy
Current Version:
Peer Reviewer:
Prof Cathy Jackson
Last Checked:
13/03/2014
Document ID:
2451 (v24)
© EMIS