• Excessive amount or duration of menstrual flow, at more or less regular intervals. Flow ≥80 mL per cycle, compared to normal average 30–40 mL (1,2).
• Distinguishable from but may overlap with the following:
  • Metrorrhagia: Irregular or frequent flow, noncyclic
  • Menometrorrhagia: Frequent, excessive, irregular flow (menorrhagia plus metrorrhagia)
  • Polymenorrhea: Frequent flow, cycles of 21 days or fewer
  • Intermenstrual bleeding: Bleeding between regular menses
  • Dysfunctional uterine bleeding (DUB): Abnormal endometrial bleeding of hormonal cause and related to anovulation
• System(s) affected: Reproductive

Prevalence

• The prevalence of abnormal uterine bleeding (AUB) is estimated at 11–13% in the general population and increases with age, reaching 24% in those aged 36–40 years (3).
• ~30% of women complain of excessive bleeding at some point (1).
• Predominant sex: Female only
• Predominant age:
  • Menarche to menopause; ~50% of cases occur in patients >40 years old
  • Dysfunctional bleeding is fairly common in adolescence and near menopause.
  • In adolescence, irregular bleeding due to anovulation and immaturity of the hypothalamic-pituitary-ovarian axis is common.

ALERT
Pediatric Considerations
Genital bleeding before puberty can result from trauma, foreign bodies, vaginal infection, or exogenous hormone administration.

Pregnancy Considerations
Bleeding in pregnancy is not menorrhagia. Complications of pregnancy or cervical/vaginal lesions should be considered.

Geriatric Considerations
True menorrhagia cannot occur after menopause. However, genital atrophy as well as uterine and ovarian cancers may be associated with vaginal bleeding in the elderly.

• Obesity
• Anovulation
• Estrogen administration (±progestin)
• Prior treatment with progestational agents or oral contraceptives increases risk of endometrial atrophy, but it decreases the risk of endometrial hyperplasia or neoplasia.

Periodic Pap smears and pelvic examinations at appropriate intervals based on age and risk factors

• Hypothyroidism
• Endometrial proliferation/excess/hyperplasia:
  • Anovulation, oligo-ovulation
  • Ovarian tumor
  • Prolonged estrogen, progestin, or oral contraceptive administration
  • Polycystic ovarian syndrome
• Local factors:
  • Endometrial atrophy, postmenopause
  • Abnormal endometrial prostaglandin levels
  • Endometrial polyps
  • Endometrial neoplasia
  • Adenomyosis/endometriosis
  • Uterine myomata (fibroids)
  • Intrauterine device (IUD)
  • Uterine sarcoma
• Coagulation disorders:
  • Thrombocytopenia, platelet disorders
  • Von Willebrand disease, factor deficiencies
  • Leukemia
  • Ingestion of aspirin/acetylsalicylic acid or anticoagulants
  • Renal failure/dialysis

Metrorrhagia, menometrorrhagia, androgenic disorders