View source for Menorrhagia

'''For patient information, click [[Menorrhagia (patient information)|here]]'''

{{Infobox_Disease |
  Name           = Menorrhagia |
  Image          = |
  Caption        = |
  DiseasesDB     = 22575 |
  ICD10          = {{ICD10|N|92|0|n|80}} |
  ICD9           = Premenopausal menorrhagia {{ICD9|627.0}} |
  ICDO           = |
  OMIM           = |
  MedlinePlus    = 003263 |
  eMedicineSubj  = |
  eMedicineTopic = |
  MeshID         = D008595 |
}}
{{SI}}
{{CMG}}

==Overview==
'''Menorrhagia''' is an abnormally heavy and prolonged [[menstruation|menstrual period]] at regular intervals. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the [[endometrium|endometrial]] lining of the [[uterus]]. Depending upon the cause, it may be associated with abnormally painful periods ([[dysmenorrhea]]).

==Definition==

A normal menstrual cycle is 21-35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL.  A blood loss of greater than 80 ml or lasting longer than 7 days constitutes menorrhagia (also called hypermenorrhea).  In practice this is not usually directly measured by patients or doctors.  Menorrhagia also occurs at predictable and normal (usually about 28 days) intervals, distinguishing it from menometrorrhagia, which occurs at irregular and more frequent intervals. It is possible to estimate the amount of bleeding by the number of tampons or pads a woman uses during her period. As a guide a regular tampon fully soaked will hold about 5ml of blood.

==Complications==
Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to [[anemia]].  Symptoms attributable to the anemia may include tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration.

==Etiology==
Usually no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. A brief overview of causes is given below, followed by a more formal medical list based on the nature of the menstrual cycle experienced.
 
===Disorders of coagulation===
With the shedding of the endometrial lining's blood vessels, normal [[coagulation]] process must occur to limit and eventually stop the blood flow.  Blood disorders of [[platelets]] (such as [[Idiopathic thrombocytopenic purpura|ITP]]) or [[coagulation]] (such as [[von Willebrand disease]]) or use of [[anticoagulant]] medication (such as [[warfarin]]) are therefore possible causes, although a rare minority of cases.

===Excessive build up in endometrial lining===
Periods soon after the onset of menstruation in girls (the [[menarche]]) and just before [[menopause]] may in some women be particularly heavy.  Hormonal disorders involving the ovaries-pituitary-hypothalamus (the 'ovarian endocrine axis') account for many cases, and hormonal-based treatments may regulate effectively.  

The lining of the womb builds up naturally under the hormonal effects of pregnancy, and an early  spontaneous [[miscarriage]] may be mistaken for a heavier than normal period.

Irritation of the endometrium may result in increased blood flow, e.g. from infection (acute or chronic [[pelvic inflammatory disease]]) or the contraceptive [[intrauterine device]] (note the distinction from the [[IntraUterine System]] which is used to treat this condition).

[[Uterine fibroids|Fibroids]] in the wall of the womb sometimes can cause increase menstrual loss if they protrude into the central cavity and so thereby increase endometrium's surface area.

Abnormalities of the endometrium such as [[adenomyosis]] (so called "internal endometriosis") where there is extension into the wall of the womb gives rise to enlarged tender uterus. Note, true [[endometriosis]] is a cause of pain ([[dysmenorrhoea]]) but usually not alteration in menstrual blood loss.

[[Endometrial carcinoma]] (cancer of the uterine lining) usually causes irregular bleeding, rather than the cyclical pattern of menorrhagia.  Bleeding in between periods ([[intermenstrual bleeding]] or '''IMB''') or after the menopause ([[postmenopausal bleeding]] or '''PMB''') should always be considered suspicious.

===Consideration by nature of the menstrual cycle===
*Excessive menses but normal cycle:
**Painless:
***[[Fibroids]]
***Ovarian endocrine disorder ([[dysfunctional uterine bleeding]] or '''DUB''')(the most common cause)
***Coagulation defects (rare)
**Painful:
***[[Pelvic inflammatory disease]]
***[[Endometriosis]]
*Short cycle (<21 days) but normal menses ([[epimenorrhoea]] or [[polymenorrhoea]]).  These are always [[anovulatory cycle]]s due to hormonal disorders.
*Short cycle and excessive menses ([[epimenorrhagia]]) due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours.
*Excessive menses and long intervals.
**Anovular ovarian disorder due to prolonged oestrogen production.
**This may occur following prolonged continuous courses of the [[combined oral contraceptive pill]] (e.g. where several packets are taken without a withdrawal gap in order to defer menstruation).

===Differential Diagnosis===
* Pregnancy complications:
** Ectopic pregnancy
** Incomplete abortion
** [[Miscarriage]]
** Threatened abortion
* Nonuterine bleeding:
** Cervical ectropion/erosion
** Cervical neoplasia/polyp
** Cervical or vaginal trauma
** Condylomata
** Atrophic vaginitis
** Foreign bodies
* Pelvic inflammatory disease (PID):
** Endometritis
** Tuberculosis
*Hypothyroidism

===Risk Factors===
* Obesity
* Anovulation
* Estrogen administration (without progestogens)
* Prior treatment with progestational agents or oral contraceptives increases the risk of endometrial atrophy, but decreases the risk of endometrial hyperplasia or neoplasia

===Drug Side Effect===
* [[Estradiol valerate and estradiol valerate/dienogest]]
* [[Misoprostol]]

===ICD-9 codes===
{|border=1 align="center" cellpadding=2
|+'''Classification of some causes'''
|-
! Cause || ICD-9 code
|- 
| Polyp of corpus uteri || {{ICD9|621.0}} 
|-
| Endometrial cystic hyperplasia || {{ICD9|621.3}} 
|-
| Other specified disorders of uterus, NEC || {{ICD9|621.8}} 
|-
| Excessive or frequent menstruation || {{ICD9|626.2}} 
|-
| Puberty bleeding || {{ICD9|626.3}} 
|-
| Irregular menstrual cycle || {{ICD9|626.4}} 
|-
| Metrorrhagia || {{ICD9|626.6}} 
|-
| Disorders of menstruation and other abnormal bleeding<br>from female genital tract, other || {{ICD9|626.8}}
|-
| Premenopausal menorrhagia || {{ICD9|627.0}} 
|-
| Postmenopausal bleeding || {{ICD9|627.1}} 
|-
|}

==Investigation==
* Pelvic and rectal examination
* Pap smear
* Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.{{ref|NICE44-2007}} 
* Endometrial biopsy to exclude endometrial cancer or atypical hyperplasia
* Hysteroscopy

==Treatment==
Where an underlying cause can be identified, treatment may be directed at this. Clearly heavy periods at the start and end of a women's reproductive years may settle spontaneously (the menopause being the cessation of periods).

If the degree of bleeding is mild, all that may be sought by the woman is the reassurance that there is no sinister underlying cause.  If anaemia occurs then [[iron]] tablets may be used to help restore normal [[hemoglobin]] levels.  Treatment may be given for a fixed period of time to replenish the body stores.  Alternatively therapy may be continued long-term, often in a cyclical regimen on the days of menstruation.

The condition is often be treated with hormones, particularly as dysfunctional uterine bleeding commonly occurs in the early and late menstrual years when contraception is also sought.  Usually oral [[Contraception|combined contraceptive]] or [[progesterone only pill|progesterone only]] pills may be taken for a few months, but for longer-term treatment the alternatives of injected [[Depo Provera]] or the more recent [[progesterone]] releasing [[IntraUterine System]] may be used.  Fibroids may respond to hormonal treatment, else require surgical removal.

[[Anti-inflammatory]] medication has previously been used, although it has a greater effect on dysmenorrhoea excess pain than on the heaviness of the period (typically 30% reduction in flow). More effective is the use of [[tranexamic acid]] tablets that may reduce loss by up to 50%. This may be combined with hormonal medication previously mentioned.

A definitive treatment for menorrhagia is to perform [[hysterectomy]] (removal of the uterus).  This historically has been associated with issues of male domination within medicine and patient's subservient roles. The risks of the procedure have been reduced with measures to reduce the risk of [[deep vein thrombosis]] after surgery, and the switch from the front abdominal to vaginal approach greatly minimising the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach.  Small fibroids may be dealt with by local removal ([[myomectomy]]).  A further surgical technique is [[endometrial ablation]] (destruction) by the use of applied heat ([[thermoablation]]).  A non-surgical approach has been the introduction and use of the [[IntraUterine System]].

In the [[United Kingdom|UK]] the use of hysterectomy for menorrhagia has been almost halved between 1989 and 2003{{ref|BMJ2005}}. This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS{{ref|JAMA-5yr}}{{ref|FertSteril}} which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery{{ref|BJOG}}.

===Treatment Options===
NOTE: Management of bleeding in pregnancy requires gynaecology referral and potential hospital admission especially if bleeding does not stop or is substantial and surgical intervention is required.

Blood transfusions may be required for blood loss resulting in compromised hemodynamic stability.

Treatment options include pharmaceutical or surgical and radiological options:

;Pharmaceutical treatments:
These have been ranked by the UK's [[National Institute for Health and Clinical Excellence]]:{{ref_label|NICE44-2007|1|a}}
* First line
** [[IntraUterine System]] insertion
*Second Line
** [[Tranexamic acid]] an antifibrinolytic agent 
** [[Non-steroidal anti-inflammatory drugs]] (NSAIDs) 
** [[Combined oral contraceptive pill]]s to prevent proliferation of the endometrium
*Third line
** Oral progestogen (e.g. [[norethisterone]]), to prevent proliferation of the endometrium
** Injected progestogen (e.g. [[Depo provera]])
*Other options
** Gonadotrophin-releasing hormone (GnRH) agonists (e.g. [[Goserelin]])

;Surgical and radiological treatments:
* Dilation and curettage (D&C) is no longer performed for cases of simple menorrhagia, having a reserved role if a spontaneous abortion is incomplete
* [[Endometrial ablation]]
* [[Uterine artery]] [[embolisation]] (UAE)
* Hysteroscopic [[myomectomy]] to remove fibroids over 3 cm in diameter
* Hysterectomy

==References==
* [http://www.infoforhealth.org/cire/cire_pub.pl Continuous Identification of Research Evidence] (collaborative of the [[WHO]], and US [[Centers for Disease Control and Prevention|CDC]] & [[Johns Hopkins Hospital]]) - [http://www.infoforhealth.org/cire/cire_pub.pl?cire_input=L-IUD Search of Evidence] about the IUS
* [http://www.guidelines.gov/summary/summary.aspx?doc_id=9579&nbr=005109&string=menorrhagia Abnormal vaginal bleeding] National Guideline Clearinghouse
* [http://www.health.am/gyneco/more/menorrhagia/ Menorrhagia - Menstrual Abnormalities and Abnormal Uterine Bleeding] Menstrual Abnormalities and Abnormal Uterine Bleeding - Armenian Medical Network
* [http://www.ngc.gov/summary/summary.aspx?doc_id=7444&nbr=4390 Abnormal uterine bleeding/dysfunctional uterine bleeding.] Intracorp - Public For Profit Organization.  2005.  Various pagings.   NGC:004390

==Footnotes==
#{{note|NICE44-2007}}{{note_label|NICE44-2007|1|a}}  {{cite web | title=CG44 Heavy menstrual bleeding: Understanding NICE guidance | url=http://www.nice.org.uk/download.aspx?o=CG044PublicInfo | format=PDF | date=24 January 2007 | publisher=[[National Institute for Health and Clinical Excellence]] (UK)}}
#{{note|BMJ2005}} {{cite journal | author = Reid P, Mukri F | title = Trends in number of hysterectomies performed in England for menorrhagia: examination of health episode statistics, 1989 to 2002-3. | journal = BMJ | volume = 330 | issue = 7497 | pages = 938-9 | year = 2005 | month=Apr 23 | id = PMID 15695496 | url=http://bmj.com/cgi/content/full/330/7497/938}}
#{{note|JAMA-5yr}} {{cite journal | author = Hurskainen R, Teperi J, Rissanen P, Aalto A, Grenman S, Kivelä A, Kujansuu E, Vuorma S, Yliskoski M, Paavonen J | title = Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up. | journal = JAMA | volume = 291 | issue = 12 | pages = 1456-63 | year = 2004 | month=Mar 24 | id = PMID 15039412}} 
#{{note|FertSteril}} {{cite journal | author = Istre O, Trolle B | title = Treatment of menorrhagia with the levonorgestrel intrauterine system versus endometrial resection. | journal = Fertil Steril | volume = 76 | issue = 2 | pages = 304-9 | year = 2001 | month=Aug | id = PMID 11476777}}
#{{note|BJOG}} {{cite journal | author = Stewart A, Cummins C, Gold L, Jordan R, Phillips W | title = The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review. | journal = BJOG | volume = 108 | issue = 1 | pages = 74-86 | year = 2001 | month=Jan | id = PMID 11213008}}
# {{note|FA}} {{cite book | author=Feig, Robert L. and Nicole C. Johnson. | title=First Aid for the Obstetrics and Gynecology Clerkship | isbn= ISBN 0-07-136423-4}}

{{Diseases of the pelvis, genitals and breasts}}
{{Symptoms and signs}}	

[[es:Menorragia]]
[[zh:经血过多]]

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[[Category:Disease]]
[[Category:Gynecology]]
[[Category:Menstruation]]