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- Menorrhagia is an excessive amount or duration of menstrual flow, at more or less regular intervals. Flow ≥80 mL/cycle, compared with 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
- Intermenstrual bleeding: Bleeding between regular menses
- Dysfunctional uterine bleeding (DUB): Abnormal endometrial bleeding of hormonal cause and related to anovulation
- System affected: Reproductive
- 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 age >40 years
- 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.
- In adolescence, severe menorrhagia may be associated with a bleeding disorder more than 40% of the time, with platelet function defects and von Willebrand disease being the most common (4).
Genital bleeding before puberty can result from trauma, foreign bodies, vaginal infection, or exogenous hormone administration.
Bleeding in pregnancy is not menorrhagia. Complications of pregnancy or cervical/vaginal lesions should be considered.
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.
Etiology and Pathophysiology
- Endometrial proliferation/excess/hyperplasia:
- Anovulation, oligo-ovulation
- Ovarian tumor or other estrogen-producing tumor
- Prolonged estrogen, progestin, or oral contraceptive administration
- Polycystic ovarian syndrome
- Local factors:
- Endometrial atrophy, postmenopause
- Abnormal endometrial prostaglandin levels
- Endometrial polyps
- Endometrial neoplasia
- Uterine myomata (fibroids)
- Intrauterine device (IUD)
- Uterine sarcoma
- Coagulation disorders:
- Thrombocytopenia, platelet disorders
- von Willebrand disease, factor deficiencies
- Ingestion of aspirin/acetylsalicylic acid or anticoagulants
- Renal failure/dialysis
- 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
Commonly Associated Conditions
Metrorrhagia, menometrorrhagia, androgenic disorders