Menorrhagia (Heavy Menstrual Bleeding)
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- The current preferred terminology for menorrhagia is “heavy menstrual bleeding” (HMB), a subcategory of “abnormal uterine bleeding” (AUB) (1).
- HMB is an excessive amount (≥80 mL/cycle, compared with normal average of 30 to 60 mL/cycle) or duration of menstrual flow at predictable intervals.
- HMB applies only to ovulatory menses
- Other patterns of AUB which may overlap with HMB include:
- Intermenstrual bleeding: bleeding between regular menses.
- Irregular bleeding: typically due to ovulatory dysfunction (encompassing the previously used terms metrorrhagia and oligomenorrhea)
- Polymenorrhea: menstrual cycle length <21 days
- System affected: reproductive
- AUB, including HMB, is thought to affect between 9% and 14% of women between menarche and menopause (2).
- AUB is more common close to menarche and menopause.
- Genital bleeding before puberty is not menstrual bleeding by definition and requires further evaluation.
- HMB presenting in adolescence is more likely related to a bleeding disorder, and patients should be evaluated for a bleeding disorder (3).
- Postmenarchal patients may have heavy and irregular menstrual bleeding related to an immature hypothalamic-pituitary axis.
Bleeding in pregnancy is not menstrual bleeding by definition and requires further evaluation. Pregnancy test should be obtained as part of the evaluation of abnormal uterine bleeding.
Menopause is diagnosed after 12 months of amenorrhea in the absence of other causes and is typically preceded by irregular bleeding. All postmenopausal bleeding requires additional workup for malignancy.
Etiology and Pathophysiology
- No cause is identified in about 1/2 of patients.
- Bleeding disorders
- Von Willebrand disease (present in about 13% of patients) (2)
- ITP and other platelet disorders
- Factor deficiencies
- Medication side effect most commonly related to anticoagulants including warfarin
- Renal failure leading to uremic platelet dysfunction
- Cirrhosis leading to coagulopathy
- Uterine fibroids, typically submucosal
- Endometrial polyps
- Iatrogenic causes including copper IUD
- Pelvic inflammatory disease
- Some causes more typically presenting as irregular menstrual bleeding include:
- Polycystic ovarian syndrome (PCOS)
- Hypothalamic-pituitary dysfunction, often postmenarchal or during menopausal transition
- Endometrial or ovarian neoplasia
- Some forms of hormonal birth control
- HMB has been associated with increased production and sensitivity to prostaglandins.
- Combined oral contraceptives may prevent HMB, particularly when progesterone is dominant. Lower estrogen doses result in less menstrual bleeding
- NSAIDs including ibuprofen inhibit prostaglandin production and result in decreased blood loss and pain during menses.
- Progesterone-only contraceptives may reduce overall blood loss but often result in irregular bleeding.
Commonly Associated Conditions
Iron deficiency anemia