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MenorrhagiaMenorrhagia is an abnormally heavy and prolonged menstrual period. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometriallining of the womb. Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrhoea).
DefinitionA normal menstrual cycle is 21-35 days in duration, with bleeding lasting an average of 7 days and total blood flow between 25 and 80 mL. A blood loss of greater than 80 ml constitutes menorrhagia, although in practice this is never directly measured by patients or doctors. ComplicationsAside 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 easier, and poor concentration. AetiologyUsually 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 coagulationWith the shedding of the endometrial lining's blood vessels, normal coagulationprocess must occur to limit and eventual stop the blood flow. Blood disorders of platelets(such as ITP) or coagulation(such as von Willebrand disease) or use of anticoagulantmedication (such as warfarin) are therefore possible causes, although a rare minority of cases. Excessive build up in endometrial liningPeriods soon after the onset of menstruation in girls (the ([menarche]]) and prior to the menopausemay 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. Naturally the lining of the womb builds up under the hormonal effects of pregnancy, and an early spontaneous miscarriagemay 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 Systemwhich is used to treat this condition). Fibroidsin 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 endometriosisis a cause of pain (dysmenorrhoea) but ususally 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 inbetween periods (intermenstrual bleedingor IMB) or after the menopause (postmenopausal bleedingor PMB) should always be consisdered suspicious. Consideration by nature of the menstrual cycle
TreatmentWhere 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 irontablets may be used to help restore normal haemoglobinlevels. 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 combined contraceptiveor progesterone onlypills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Proveraor the more recent progesteronereleasing IntraUterine Systemmay be used. Fibroids may respond to hormonal treatment, else require surgical removal. Anti-inflammatorymedication 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 acidtablets 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 hysterectomyremoval of the womb. 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 thrombosisafter 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 of applied heat (thermoablation). A non-surgical approach has been the introduction and use of the IntraUterine System. In the UKthe use of hysterectomy for menorrhagia has been almost halved between 1989 and 2003[{{fullurl:Template:FULLPAGENAME}}#endnote_BMJ2005]. This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS[{{fullurl:Template:FULLPAGENAME}}#endnote_JAMA-5yr][{{fullurl:Template:FULLPAGENAME}}#endnote_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[{{fullurl:Template:FULLPAGENAME}}#endnote_BJOG]. References
Categories: Gynecology
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