Defined as menstrual blood loss exceeding 80 mL per cycle.
Prevalence of 9%-15% in otherwise healthy women.
Accounts for 18 to 20% of gynecological office visits.
Heavy menstrual bleeding is common and a distressful condition with a lifetime prevalence of 30%.
It is defined largely by the patient’s perception, aided by clues such as soaking a pad or tampon more than every two hours during peak flow, large blood clots, , and interference with activities of daily living.
About one in20 women age 30-49 consult their physician because of menstrual disorders.
Less than half of women who experience heavy menstrual bleeding seek medical help.
Heavy menstrual bleeding is associated with the reduced health quality of life due to irritation, inconvenience, pain, and self consciousness, and social embarrassment.
Etiologies of abnormal uterine bleeding includes: polyps, adenomyosis,leiomyoma, malignancy, hyperplasia, coagulopathy, ovarian dysfunction, endometrial, iatrogenic, and undetermined.
More than 5% of women age 30-49 years consult their physicians with this problem annually.
Rates of surgical procedures for this problem are 17.8 per 10,000 women 25-44 years of age in the US.
Substantial difference between objective measures of menstrual blood flow and a woman’s perception of the amount of bleeding is present.
Because it is difficult to measure the amount of blood during a menstrual period, definition of clinical guidelines reflect the physical, emotional and social life interference that a woman with heavy menstrual bleeding s experiencing.
Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals.
Menorrhagia can be caused by abnormal blood clotting, disruption of normal hormonal regulation of periods, or
disorders of the endometrial lining of the uterus.
May be associated with abnormally painful periods, dysmenorrhea.
A normal menstrual cycle is 25–35 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
defines menorrhagia.
Occurs at predictable and normal intervals, distinguishing it from menometrorrhagia, which occurs at irregular and
more frequent intervals.
To estimate the amount of bleeding by the number of tampons or pads a woman uses during her
period, it is assumed that a regular tampon fully soaked will hold about 5ml of
blood.
Lighter blood flow more than seven days also can constitute menorrhagia.
Usually no causative abnormality can be identified.
Most common causes include blood disorder or stress-related disorders.
With the shedding of an endometrial lining’s blood vessels with menstruation hemostasis must occur to limit and stop the blood flow.
Disorders of platelets or coagulation, or use of anticoagulants medication are possible causes, but makeup a minority of cases.
Hormonal disorders involving the ovary-pituitary-hypothalamus axis can account for many cases.
With aging ovulation becomes delayed and the remaining follicles in the ovaries become resistant to Gonadotropin releasing hormone (GnRH) secreted by the hypothalamus, or eggs do not develop resulting in decreased/absent progesterone production.
Unopposed estrogen causes thickening of the endometrial lining, which would normally be shed regularly and moderately, to shedding irregularly and heavily.
As a result of the above no progesterone is produced, and estrogen is
unopposed and building up the lining of the uterus.
During a woman’s period the endometrial lining which is normally shed during a period, but with aging it never gets the signal to stop thickening as it keeps growing and sheds
irregularly.
The extra thickness of the uterus results the is unusually
heavy bleeding.
Less frequently in this age group, too little estrogen can be the cause of
irregular bleeding.
Irritation of the endometrium may result in increased menstrual blood flow, due to
infection (acute or chronic pelvic inflammatory disease) or a
contraceptive intrauterine device,
Fibroids in the wall of the uterus sometimes can cause increased
menstrual loss.
Fibroids may protrude into the central uterine cavity and increase endometrium’s surface area.
Endometrial carcinoma usually causes irregular bleeding, rather than the cyclical pattern of menorrhagia.
May be associated with increased blood flow from acute or chronic pelvic inflammatory disease, contraceptive intrauterine device, and fibroids.
Endometrial carcinoma usually causes irregular bleeding, rather than the cyclical pattern of menorrhagia.
Excessive menses but normal cycle without pain may be associated with fibroids, dysfunctional uterine bleeding, coagulation defects and endometrial polyps.
Excessive menses associated with pain include: Pelvic inflammatory disease, endometriosis, and adenomyosis.
Short cycle but normal menses are always anovulatory cycles due to hormonal disorders.
Short cycle and excessive menses can be due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumors.
Excessive menses and long intervals may be seen in anovular ovarian disorder due to prolonged estrogen production such as may occur following prolonged continuous courses of the combined oral contraceptive pill.
Differential Diagnosis includes:
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 include: obesity, anovulation, estrogen administration, prior progestational exposure, and prior oral contraceptives.
The levonorgestrel intrauterine system Is more effective than usual medical treatment in reducing the effect of heavy menstrual bleeding on the quality of life (Gupta J et al).