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.