Causes, treatments & clinical consequences of menorrhagia in women aged 18-30
What is Menorrhagia?
● Heavy or prolonged menstrual
blood loss that occurs regularly
(every 24-35 days).
● Normal blood loss during periods
is around 30-40ml.
● With menorrhagia: 1
○ > 80 ml of blood loss during
period
○ Prolonged period over 7
days
● The best way to diagnose it is to
understand the impact the
bleeding has on the patient’s life
What is it like to live with: 2
Interferes with a woman's physical,
emotional, social, and material quality of
life:
● Fatigue and breathlessness
● Consequently avoid activities on
period
● Pass blood clots larger than 2.5cm
● Need to use multiple sanitary
products together to avoid risk of
leaking through
● Bleeding through clothes or
bedding which is called flooding
Prevalence:
Excessive Uterine Bleeding will be experienced at least
once by 25% of UK women in their reproductive age.3
● Increases with Age, greatest proportion in women
aged 30-494
● 5% in this group consult GP for menorrhagia,
annually.4
In Comparison, a self-reported study run in Beijing found:
● Prevalence 18.2%5
This shows similar rates are experienced across
populations globally.
Causes of menorrhagia: 6
Hormone imbalance: There is usually a balance between
oestrogen and progesterone - both help shed the uterus
lining near the end of the menstrual cycle (day 28)
Polycystic ovary syndrome (PCOS): Can also be due to
obesity and thyroid problems
Ovary dysfunction: progesterone isn’t released due to
missing egg leading to hormone imbalance
Uterine fibroids: benign tumours that appear on uterus
Intrauterine device: birth control, menorrhagia is a
side-effect
Von Willebrand’s disease: important blood clotting factor
is deficient/impaired causing abnormal menstrual bleeding
Other causes include -
Pregnancy complications e.g - ectopic pregnancies
Uterine/cervical cancer
Signs & Symptoms 6 , 7
● Abdominal pain & dysmenorrhea
● Period of > 7 days
● Passing blood clots larger than a coin
● Losing > 80 ml of blood
Complications
● Anaemia
- reduces the no. of circulating red
blood cells so iron stores fall
- Increases the risk of IDA
- Signs & symptoms of anaemia
include - pallor, fatigue and
weakness
● Restricting usual activities e.g. - going
out
Diagnosis
● Family history of heavy bleeding
● No. of days of heavy bleeding
● Pregnancy history, current birth control
methods and current medications
Tests
● Sonohysterogram
● Hysteroscopy (to check for polyps,
fibroids, etc)
● Pap smear & Endometrial biopsy
Overview of Primary care treatment
Primary Care Pathway 8 :
1) Levonorgestrel intrauterine system
(LNG-IUS) (hormonal contraceptive)
2) Non-hormonal: tranexamic acid
(anti-fibrinolytic – stops breakdown of fibrin
clot 11) or NSAID (unselective COX1&2
inhibition – results in inhibition of
thromboxane signalling needed for
coagulation and activation of platelets)
3) Hormonal: combined hormonal
contraception (CHC) or a cyclical oral
progestogen (progesterone reduces
bleeding by acting as an inhibitor of the
growth of the lining of the uterus 10 )
4) Surgical: Hysterectomy, Hysteroscopic
Removal of submucosal fibroids 9,
Myomectomy (removal of fibroids)
5) Further Tests
References (Vancouver) -
1. CKS. Menorrhagia [Internet]. NICE. 2018 [cited 2022 Oct 11]. Available from: https://cks.nice.org.uk/topics/menorrhagia/
2. NHS Wales. Heavy Periods, Menorrhagia [Internet]. 111.wales.nhs.uk. 2021 [cited 2022 Oct 11]. Available from:
https://111.wales.nhs.uk/Heavyperiods
3. BMJ (2017b). Menorrhagia. BMJ Best Practice [Internet]. 2017 [cited 2022 Oct 11]. Available from: http://www.bestpractice.bmj.com
4. BMJ (2017a). Menorrhagia. BMJ Best Practice [Internet]. 2017 [cited 2022 Oct 11]. Available from: http://www.bestpractice.bmj.com
5. Ding, C., Wang, J., Cao, Y. et al. Heavy menstrual bleeding among women aged 18–50 years living in Beijing, China: prevalence, risk factors,
and impact on daily life. BMC Women's Health 19, 27 (2019). https://doi.org/10.1186/s12905-019-0726-1
6. Mayo Clinic. Menorrhagia (heavy menstrual bleeding) - Symptoms and causes [Internet]. Mayo Clinic. 2017 [cited 2022 Oct 11]. Available
from: https://www.mayoclinic.org/diseases-conditions/menorrhagia/symptoms-causes/syc-20352829
7. Cleveland Clinic. Menorrhagia: Symptoms, Causes, Treatments [Internet]. Cleveland Clinic. 2021 [cited 2022 Oct 11]. Available from:
https://my.clevelandclinic.org/health/diseases/17734-menorrhagia-heavy-menstrual-bleeding
8. Scenario: Management of menorrhagia (heavy menstrual bleeding) [Internet]. NICE. 2018 [cited 2022 Oct 11]. Available from:
https://cks.nice.org.uk/topics/menorrhagia/management/management/
9. Fibroids [Internet]. NHS.uk. 2022 [cited 2022 Oct 11]. Available from:
www.nhs.uk/conditions/fibroids/#:~:text=Fibroids%20are%20non%2Dcancerous%20growths.
10. What are the treatment options for heavy periods? [Internet]. Nih.gov. Institute for Quality and Efficiency in Health Care (IQWiG);
2017.[cited 2022 Oct 11] Available from: https://www.ncbi.nlm.nih.gov/books/NBK279293/
11. Cai J, Ribkoff J, Olson S, Raghunathan V, Al-Samkari H, DeLoughery TG, et al. The many roles of tranexamic acid: An overview of the clinical
indications for TXA in medical and surgical patients. European Journal of Haematology [Internet]. 2019 Dec 16 [cited 2022 Oct
11];104(2):79–87. Available from: https://onlinelibrary.wiley.com/doi/10.1111/ejh.13348