Treatment of Menorrhagia

Menorrhagia is defined as excessive uterine bleeding occurring at regular intervals or prolonged uterine bleeding lasting more than seven days. The classic definition of menorrhagia (i.e., greater than 80 mL of blood loss per cycle) is rarely used clinically.

Women describe the loss or reduction of daily activities as more important than the actual volume of bleeding. Routine testing of all women with menorrhagia for inherited coagulation disorders is unnecessary. Saline infusion sonohysteroscopy detects intracavitary abnormalities such as endometrial polyps or uterine leiomyoma and is less expensive and invasive than hysteroscopy.

Endometrial biopsy is effective for diagnosing precancerous lesions and adenocarcinoma but not for intracavitary lesions. Except for continuous progestin, medical therapies are limited. The levonorgestrel-releasing intrauterine device is an effective therapy for women who want to preserve fertility and avoid surgery.

Surgical therapies include endometrial ablation methods that preserve the uterus; and hysterectomy, which results in high satisfaction rates but with potential surgical morbidity. Overall, hysterectomy and endometrial ablation result in the greatest satisfaction rates if future childbearing is not desired. Treatment of menorrhagia results in substantial improvement in quality of life.

The term “abnormal uterine bleeding” encompasses noncyclic and cyclic bleeding. Anovulatory bleeding is the most common type of noncyclic uterine bleeding. Menorrhagia is defined as excessive cyclic uterine bleeding that occurs at regular intervals over several cycles, or prolonged bleeding that lasts for more than seven days. Anovulatory bleeding and menorrhagia, although often grouped together in discussions of treatment, do not have the same etiology or require the same diagnostic testing.

Average menstrual blood loss is between 30 and 40 mL per cycle. An early population-based study concluded that the upper limit of normal menstrual blood loss was between 60 and 80 mL, with the upper limit subsequently adopted as the classic definition of menorrhagia. A greater prevalence of impaired iron status was noted with a loss of more than 60 mL. There are shortcomings to this volume definition because actual blood loss is largely subjective and difficult to quantify objectively.

In 34 percent of women, the subjective complaint of “heavy periods” appears to correlate with a significantly higher quantified average blood loss. Some women, however, do not consider heavy menstrual flow to be abnormal. Of women who rated their flow as very heavy, 25 percent had losses of less than 35 mL per cycle, and 25 percent of those who rated their periods as heavy had losses of more than 82 mL. Physicians may be unable to judge volume from patient history or may consider measurements unimportant in deciding treatment. Pictorial blood loss assessment charts may not accurately reflect the hygiene products used. Additionally, women change hygiene products at a varied frequency whether saturation has occurred or not. Therefore, the criterion of loss of more than 80 mL is of doubtful clinical significance.

The clinical features associated most strongly with blood loss volume include the rate of change of sanitary protection during full flow, and the total number of pads and tampons used. Other associations include the size of clots and the number of clots greater than about 1 inch in diameter. A low ferritin level correctly predicts 60 percent of women with periods with measured losses of more than 80 mL; therefore, a loss of more than 80 mL can be predicted moderately well by a model that includes ferritin levels, clot size, and the rate of pad change during full flow.

Dysmenorrhea, mood change, and a perceived increase in the volume of menstrual bleeding are reported more often as severe problems by women with menorrhagia than is absolute blood loss. Patient distress may be related more to disruptions in work, sexual activity, or quality of life than menstrual volume alone. These perceptions are important, because the amount of blood loss alone is not linked to a decision to proceed with hysterectomy. A woman’s perception of blood loss and the disruption that it causes are the key determinants of subsequent treatment.

Risk Factors

Established risk factors for menorrhagia include increased age, premenopausal leiomyomata, and endometrial polyps. Parity, body mass index, and smoking are not risk factors. For some women, a cause of menorrhagia is not identified.

Abnormalities of platelet function, such as von Willebrand’s disease, appear to be more prevalent in women with menorrhagia than in the general population. The prevalence of von Willebrand’s disease in women with menorrhagia varies from 5 to 24 percent. There are no data suggesting that a lower quality of life occurs more commonly in women with menorrhagia and von Willebrand’s disease than in those with menorrhagia alone.

BARBARA S. APGAR, MD, MS, AMANDA H. KAUFMAN, MD, UCHE GEORGE-NWOGU, MD, and ANNE KITTENDORF, MD, University of Michigan Medical Center, Ann Arbor, Michigan

BARBARA S. APGAR, MD, MS, is a professor of family medicine at the University of Michigan Medical Center, Ann Arbor. She received her medical degree and completed a family medicine residency at Texas Tech Health Sciences Center in Lubbock. Dr. Apgar is also an associate editor for American Family Physician.

AMANDA H. KAUFMAN, MD, is a lecturer of family medicine at the University of Michigan Medical Center. She received her medical degree and completed a family medicine residency at the University of Michigan.

UCHE GEORGE-NWOGU, MD, is an instructor and assistant residency director of family medicine at the University of Michigan Medical Center. She received her medical degree from the University of Ibadan in Nigeria, and completed a family medicine residency at New York University Medical School at St. Joseph Hospital in New York City.

ANNE KITTENDORF, MD, is a lecturer of family medicine at the University of Michigan Medical Center. She received her medical degree and completed a family medicine residency at the University of Michigan.

Address correspondence to Barbara Apgar, MD, MS, 883 Sciomeadow Dr., Ann Arbor, MI 48103 (e-mail: .(JavaScript must be enabled to view this email address)). Reprints are not available from the authors.

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