MENORRHAGIA


I. Defined as > 80-90ml/period; only 2/5 of women who c/o excessive bleeding actually exceed this amount

II. Hx

  1. Bleeding elsewhere?
  2. Strictly limited to part of each month?

III. Work-up

  1. Always r/o PREGNANCY!
  2. CBC to r/o anemia which occurs in 2/3 of women, and thrombocytopenia
  3. PT/PTT
  4. TSH
  5. Consider endometrial bx esp. if there is intermenstrual bleeding
  6. Consider u/s to look for fibroids

IV. Tx: start with medical; surgery rarely necessary

  1. NSAIDs
  1. Initial tx of choice
  2. Inhibit prostaglandin synthesis and cause uterine vasoconstriction
  3. Also help with dysmenorrhea which is common in these women
  4. Mefanamic acid (Ponstel) 500 TID has been studies most, but ibuprofen 400 QID, naproxen 375 BID, indocin 25 TID also found to be effective at reducing blood loss
  1. Hormones
  1. OC's (if pt doesn't want to get pregnant)
  2. Levonorgestrel-containing IUD's
    1. Control bleeding (BMJ 316:1122, 1998--JW) but may be ass'd with higher risk ectopic preg. than other IUD's
    2. 232 women with menorrhagia (mean age 43yo) randomized to levonorgestrel-releasing IUD vs. hysterectomy; no sig. diff. in improvements in health-related quality of life at 5y (JAMA 291:1456, 2004--JW)
    3. More effective at reducing volume of menorrhagia than an NSAID (mefemanic-acid) in one 6mo randomized trial (Br. J. Obs. Gyn. 112:1121, 2005--JW)
    4. In a study in 162 women with menorrhagia randomized to levonorgestrel-releasing IUD vs. monthly oral medroxyprogesterone acetate 10mg/d x 10d; over 6mos, the IUD group had sig. higher incidence of > 50% reduction in blood loss (80% vs. 30%) (Obs. Gyn. 116:625, 2010-JW)

  3. Cyclic progesterone, e.g. Provera 10-20mg QD for days 16-25 of each month (doesn't prevent pregnancy!)-not used much anymore
  4. GnRH agonists, e.g. Lupron, to reduce estrogen levels; however, expensive and prolonged use may cause osteoporosis
  5. Danazol (a synthetic androgen with antiestrogenic properties)-reduces blood flow more than NSAIDs but expensive and more side f/x (acne, spotting, hot flashes, hirsutism, etc.)
  1. Tranexamic acid (Lysteda)
    1. An oral fibrinolysis inhibitor
    2. Effective at 1300mg TID (for up to 5d during menses; adjust dose in renal impairment) for controlling bleeding in pts with menorrhagia
    3. Associated with headaches,sinus pain, myalgias, arthralgias, anemia, and fatigue.
    4. Also, theoretical possibility of increased risk for thrombosis.

 

  1. Surgery
  1. Hysterectomy
    1. In a study in 63 premenopausal women 30-50yo with menorrhagia not adequately controlled on cycloc medroxyprogesterone acetate randomized to hysterectomy vs. medical therapy (combined OCPs + a prostaglandin inhibitor); at 6mos, surgery group had sig. greter improvements in pelvic pain, breast pain, and urinary urgency; at 2y, surgery group had sig. less hot flashes and incomplete bladder emptying (Obs. Gyn. 103:824, 2004--AFP)
  2. D & C-only temporary solution
  3. Endometrial ablation (variety of techniques)
    1. Usually prevents subsequent pregnancy
    2. 20% go on to have hysterectomy
    3. Radio-frequency ablation
      1. In a randomized study of 126 women with menorrhagia randomized to RF ablation vs. hot-water-balloon ablation therapy, prevalence of amenorrhea was sig. greater in RF group at 3mos and 12mos (for the latter was 43% vs. 8%); pt satisfaction was also sig. greater at 12mos with RF treatment (BJOG 111:1095, 2004--AFP)
  1. Comparisons among treatments for menorrhagia
    1. In a meta-analysis of 30 randomized trials of treatment for menorrhagia, endometrial ablation was associated with sig. higher dissatisfaction rates than with hysterectomy (11-13% vs. 5%) but with no sig. difference from levonorgestrel-releasing IUDs (BMJ 341:c3929, 2010; e-pub ahead of printing at: http://dx.doi.org/10.1136/bmj.c3929).

(Sources include AFP 53:165, 1996)