Definition

The menstrual cycle varies from woman to woman. Normal menstrual flow occurs every 21-35 days, lasts 4-5 days and produces a blood loss of 30-40mls. Menorrhagia is clinically defined as menstrual blood loss that exceeds 80mls per cycle or menstruation that lasts longer than 7 days.

Causes

In 30% of Menorrhagia, an organic cause is found, predominantly gynaecological in nature. However, in the other 70% of cases, no organic cause can be found and this is termed Dysfunctional Uterine Bleeding (DUB). This is a diagnosis of exclusion only.

Organic Causes

• Fibroids: These are usually benign uterine tumours present in at least 30% of women of reproductive age. Although most do not cause symptoms, Fibroids may cause heavy or prolonged menstrual bleeding and a feeling of pressure in the pelvis. The risk of cancer in fibroids is very small (less than 1%).

• Adenomyosis: This condition occurs when endometrial glands become embedded in the uterine muscle, which respond by rapid growth of muscle and fibrous tissue causing heavy bleeding and pain. Symptomatically, it is difficult to differentiate from uterine fibroids.

• Polyps: These are small, usually benign, growths on the lining of the uterine wall occurring in women of reproductive age. They can be multiple and tend to recur and in some cases may be pre-cancerous.

• Pelvic Inflammatory Disease (PID): Irrespective of the cause of PID, this may present with heavy menstrual bleeding. There is a peak incidence in the 25-35 year old age group.

• Endometriosis: This is a disorder in which foci of endometrial tissue exist beyond the uterine cavity. Menstrual irregularities, including heavy menstrual bleeding form part of its spectrum of symptoms.

• Cancer: Although infrequent, gynaecological cancers especially uterine cancer can cause excessive menstrual bleeding.

• Pregnancy Complications: A single late heavy period may be due to a miscarriage or ectopic pregnancy. This is unlikely though if bleeding occurs at the normal time of menstruation.

• Other Disease: These are varied and include thyroid disease (both under and over active disease), kidney and liver disease, obesity, bleeding disorders and the use of blood-thinning medications.

Non-Organic

When no pathology is found to account for heavy menstrual bleeding, it is termed Dysfunctional Uterine Bleeding and is a diagnosis of exclusion only. DUB tends to occur at the extremes of reproductive age (under 19 and over 39 years) and the cause is unclear but is likely due to anovulation and the associated hormonal imbalance. Without ovulation there is no progesterone secretion, making the oestrogen secretion unopposed. This allows the endometrium to proliferate and thicken, outgrowing its blood supply. Eventually the endometrium degenerates resulting in erratic breakdown of the endometrial lining and causing heavy menstrual bleeding.

Symptoms

Symptoms characteristically on Menorrhagia may include:

• Occurrence of flooding
• Saturation of pads/tampons every hour for several consecutive hours.
• The use of double sanitary protection to control flow
• The need to change sanitary protection during the night
• Menstrual periods lasting longer than 5 days
• The presence of large clots
• Lower abdominal discomfort
• Symptoms of anaemia including fatigue, shortness of breath palpitations and pallor.

Diagnosis

A detailed medical and menstrual history will be sought followed by a general physical examination, abdominal examination and internal pelvic examination. In addition to, and depending on the results of these, the following tests may be recommended:

• Blood Tests -- these are requested to rule out thyroid disease and blood-clotting abnormalities as well as to check for any resultant anaemia from the heavy menstrual bleeding.

• Ultrasound Scan -- this is done to visualise the pelvic and reproductive organs for organic gynaecological causes.

• Hysteroscopy & Endometrial Biopsy -- This is used to directly visualise inside the uterine cavity for abnormalities such as polyps, fibroids and a thickened endometrium. A sample is taken for further histological (microscopic) examination.

Treatment of Menorrhagia

Treatment of Menorrhagia must be tailored to the individual, taking into account, any underlying cause, the severity of bleeding, co-existing medical problems, family history, age, desire for fertility and personal lifestyle factors.

The first point to consider is treatment of underlying organic pathology. For example:

• Removal of an IUD
• Surgical removal of Fibroids, Polyps, Endometriosis or Adenomyosis
• Treatment of infection for Pelvic Inflammatory disease
• Drug therapy for thyroid disease
• Medical treatment of coagulopathies
• Losing weight if obesity is the cause.

However, in the 70% of cases where no pathology is identified (DUB) treatment options fall into 2 groups.

1. Medical

Medical approaches are centred around hormonal treatment, use of non-steroidal anti-inflammatory drugs (NSAID’s) or anti-fibrinolytic medications.

A. Hormonal Treatments

• Oral Contraceptive Pill (OCP) -- These are popular first line therapy for women who desire non-permanent contraception where Menorrhagia is mild.

• Mirena IUD -- this is a progestigen impregnated IUD which causes the endometrium to shrivel thereby stopping the bleeding. Reduction in blood loss can be as high as 80-90% after 3-6 months. This also affords a good method of non-permanent contraception, as it is effective for up to 5 years.

B. Non-Steroidal Anti-Inflammatory Drugs (NSAID’s)

These decrease blood loss by 25-30%. They are used only during menstruation, thereby limiting their most common adverse effect of stomach upset. These have the added benefit of relieving painful menstrual cramps. They do not provide any contraception.

C. Anti-Fibrinolytic Medication

These may reduce blood loss by up to 50%. They are taken only during the first 2-3 days of the menstrual cycle, and side effects are usually minimal. However, compliance issues can become a concern, as 8 tablets per day need to be taken during menstruation.

2. Surgical

Surgical management is indicated in dysfunctional uterine bleeding when medical therapy cannot be tolerated or fails to alleviate symptoms. It also considered when definitive treatment is sought in those for whom childbearing is complete or have no fertility concerns.

A. Endometrial Ablation

This is a minimally invasive procedure done as a day-case under general anaesthetic, whereby the full thickness of the endometrial lining of the uterus is destroyed. The success rate for endometrial ablation is quite high with most women reporting minimal or no pain associated with the procedure. In fact, the vast majority of women can return to work and normal activities the next day after the procedure.

B. Hysterectomy

This provides a definitive cure for dysfunctional uterine bleeding, but is generally performed as a last resort when other treatment options have been trailed and failed, or when other co-existing gynaecological conditions warrant this treatment method (for example prolapse)

Although Hysterectomies can be performed by one of three methods, Laparoscopic Hysterectomy is associated with fewer complications and more favourable outcomes than the abdominal approach, as it is less invasive and less traumatic way to remove the uterus. The vaginal approach is suitable for who have some degree of uterine prolapse.

Irrespective of the medical or surgical options to reduce menstrual bleeding, iron supplements may need to be taken if significant anaemia is present.