This page has moved. Click here to view.
Menorrhagia (excessive bleeding) is most commonly caused by anovulatory menstrual cycles. Occasionally it is caused by thyroid dysfunction, infections or cancer. Menorrhagia caused by anovulation is referred to as dysfunctional uterine bleeding.
Pathophysiology of Normal Menstruation
In response to gonadotropin-releasing hormone from the hypothalamus, the pituitary gland synthesizes follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which induce the ovaries to produce estrogen and progesterone.
During the follicular phase, estrogen stimulation causes an increase in endometrial thickness. After ovulation, progesterone causes endometrial maturation and secretory changes. Menstruation is caused by estrogen and progesterone withdrawal.
Abnormal bleeding is defined as bleeding that occurs at intervals of less than 21 days, more than 36 days, lasting longer than 7 days, or blood loss greater than 80 mL.
Clinical Evaluation of Abnormal Bleeding
A menstrual and reproductive history is obtained, including last menstrual period, regularity, duration, and frequency; the number of pads used per day and the presence of intermenstrual bleeding should be assessed.
Stress, exercise, weight changes and systemic diseases, particularly thyroid, renal or hepatic diseases, or coagulopathies should be sought. The method of birth control should be determined.
Pregnancy complications, such as spontaneous abortion, ectopic pregnancy, placenta previa and abruptio placentae, can cause non-cyclical, heavy bleeding. Pregnancy should always be considered as a possible cause of abnormal uterine bleeding.
Determine Whether the Patient Is Having Ovulatory or Anovulatory Cycles
Ovulatory cycles are characterized by menstrual flows occurring at regular intervals, preceded by premenstrual symptoms (breast tenderness or fullness, pelvic cramping, and edema).
If cycles are anovulatory, the patient has dysfunctional uterine bleeding.
Puberty and Adolescence--Menarche to age 16
Irregularity is normal during the first few months of menstruation; however, soaking more than 25 pads or 30 tampons during a menstrual period is abnormal.
Absence of premenstrual symptoms (breast tenderness, bloating, cramping) is associated with anovulatory cycles.
Fever, particularly in association with pelvic or abdominal pain may, indicate pelvic inflammatory disease. A history of easy bruising suggests a coagulation defect. Headaches and visual changes suggest a pituitary tumor.
Physical Findings
Pallor not associated with tachycardia or signs of hypovolemia suggests chronic excessive blood loss, such as that occurring with anovulatory bleeding, adenomyosis, uterine myomas, or blood dyscrasia.
Signs of impending shock indicate that the blood loss is likely related to pregnancy (including ectopic), trauma, sepsis, or neoplasia.
Pelvic masses may represent pregnancy, uterine or ovarian neoplasia, or a pelvic abscess or hematoma.
Fever, leukocytosis, and pelvic uterine bleeding, vaginal, menstruation, bleeding, heavy period, menstrual tenderness suggests PID.
Fine, thinning hair, and hypoactive reflexes suggest hypothyroidism.
Ecchymoses or multiple bruises may indicate trauma, coagulation defects, medication use, or dietary extremes.
Laboratory Tests
CBC and platelet count and a urine or serum pregnancy test should be completed.
Screening for sexually transmitted diseases, thyroid function, andcoagulation disorders (partial thromboplastin time, INR, and bleeding time) is necessary.
Endometrial sampling is rarely necessary for those under age 20.
Treatment of Infrequent Bleeding
Therapy should be directed at the underlying cause when possible.
If the CBC and other initial laboratory tests are normal and the history and physical examination are normal, reassurance is usually all that is necessary.
Ferrous gluconate, 325 mg bid-tid, should be prescribed.
Treatment of Frequent or Heavy Bleeding
Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) improve platelet aggregation and increase uterine vasoconstriction.
NSAIDs are the first choice in the treatment of menorrhagia because they are well tolerated and they do not have the hormonal effects of oral contraceptives. Additionally, women with menorrhagia frequently also have dysmenorrhea, and NSAIDs are effective for this problem.
Specific Agents
Mefenamic acid (Ponstel) 500 mg tid daily for 3 days during the menstrual period.
Naproxen (Anaprox, Naprosyn) 500-mg loading dose, then 250 mg three times daily for 3 days during the menstrual period.
Ibuprofen (Motrin, Nuprin) 400-600 mg tid during the menstrual period.
These agents are equally effective. Gastrointestinal distress is common, and NSAIDs are contraindicated in renal failure and peptic ulcer disease.
Iron should also be added as ferrous gluconate 325 mg tid.
Patients with hypovolemia or a hemoglobin level below 7 g/dL should be hospitalized for hormonal therapy, iron replacement, and possibly transfusion.
Hormonal therapy consists of estrogen (Premarin) 25 mg IV q6h until bleeding stops. Thereafter, oral contraceptive pills should beadministered q6h x 7 days, then taper slowly to one pill qd.
If bleeding continues, IV vasopressin (DDAVP) should be administered. Hysteroscopy may be necessary, and dilation and curettage is a