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Menorrhagia: a clinical update

Carl E Wood

Almost every woman experiences episodes of abnormal or excessive menstrual bleeding

MJA 1996; 165: 510-514

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Introduction - Assessment of blood loss - Causes - Diagnosis - Management - Drug therapy - Surgery - References - Authors' details

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Introduction

 Menorrhagia is defined as a blood loss of 80 mL or more per period. Population studies show that the typical menstrual blood loss is 30-40 mL, and that 90% of women have losses of less than 80 mL. 1 Menorrhagia is still one of the more common reasons for women to be referred to a gynaecologist, and is the main presenting symptom in 38% of Australian women having hysterectomies. 2

Box 1 summarises the stages in clinical assessment and management of menorrhagia.

1: Assessment and management of menorrhagia

Assessment of blood loss

Women seeking treatment for menorrhagia often do not have greater blood losses than average. In a population study, 26% of women with normal menstrual loss ( < 60 mL) considered their periods heavy, while 40% of those with heavy losses ( > > 80 mL) considered their periods to be moderate or light. 1 In one study, over half the women referred for endometrial ablation complaining of heavy periods had menstrual blood losses of less than 80 mL. 3 Social embarrassment, inconven ience, costs of sanitary protection, the safety of using tampons, and interference with sexual activity all make coping with menstruation difficult.

An approximate assessment of blood loss can be made from a pad and tampon count. 4 If blood loss does not appear excessive, then counselling on how best to manage menstrual loss may avoid unnecessary drug treatment or surgical intervention.

Causes

The volume of blood lost at menstruation is controlled by local uterine vascular tone, haemostasis, and regeneration of endometrium. Studies of patients with menorrhagia have shown a greater endometrial concentration of the vasodilator prostaglandin E (PGE), 5,6 and a relationship between total prostaglandin (PGE, PGI 2 and PGF 2 a ) concentration and average blood loss. 6 Increased endometrial fibrinolysis may be of importance, 7 as suggested by reduction in mean menstrual blood loss in women taking fibrinolytic inhibitors (e.g., tranexamic acid). 8

The wide variety of causes of menorrhagia are shown in Box 2. The frequency of the organic causes in a normal population is not known.

Anovulation may be associated with menorrhagia close to menarche and to menopause. It may be particularly important when prolonged menstrual cycles occur, as oestrogen in the absence of progesterone may cause endometrial hyperplasia, atypical hyperplasia and eventually carcinoma. Progesterone alone or progesterone associated with the oral contraceptive pill prevents such changes.

Management of women with menorrhagia may be more effective if psychosocial factors (depression, work difficulties, heavy smoking [> 20 per day], excessive alcohol intake, and sexual problems) 9,10 are taken into consideration.

Diagnosis

The main diagnostic procedures for menorrhagia include:

Dilatation and curettage (D&C) involves a general anaesthetic and a one-day stay in hospital; it is not cost effective for diagnosing endometrial malignancy in women under 40 years (who have a low prevalence of serious uterine conditions and endometrial cancer). 11 The potential benefits need to be weighed up against the risks (general anaesthesia and possible uterine perforation and laceration of the cervix). 12 Moreover, a significant proportion of endometrial lesions are not detected by D&C, 12,13 and its usefulness as a diagnostic tool has been repeatedly questioned. 12,14,15

Endometrial sampling and hysteroscopy: Endometrial sampling (the passage of intrauterine catheters which scrape or brush the endometrial surface) or hysteroscopy (which enables targeted biopsy of abnormal endometrium) have high levels of patient acceptability, lower complication rates, usually do not require inpatient admission and general anaesthesia, and are as accurate and cost effective as D&C. 15-17

Vaginal ultrasound: Ultrasound diagnosis markedly increases the accuracy of clinical diagnosis and assists in treatment choice (including avoidance of surgery) and selection of patients most suited to endometrial resection, intrauterine resection of polyps and fibromyomas, open, vaginal or laparoscopic myomectomy, adenomyomectomy and hysterectomy. 18

Management

Drug therapy

Over the last decade, a wide variety of drugs have been used for the treatment of menorrhagia (Box 3). Medical treatment avoids major surgery, but has associated side effects and is generally only effective for the duration of treatment.

Thirty-one randomised controlled trials of drug therapy with objective measurement of menstrual blood loss have been published. The one controlled study, comparing tranexamic acid (1 g given four times daily on Days 1-4 of menstruation) and norethisterone taken on Days 9-26, showed tranexamic acid to be more effective and with no significant side effects. Although isolated case reports of thrombotic episodes with tranexamic acid exist, a Scandinavian study of 238 000 treatments with this drug over 19 years showed no increased thrombotic events compared with those in an age-matched general population. 22 The possibility of minor subclinical thrombosis with long term use can be excluded only by a follow-up study.

In women with a pretreatment blood loss of 80-200 mL per cycle, 92% had their blood loss reduced to less than 80 mL per cycle with tranexamic acid. Those with a menstrual blood loss of more than 250 mL per cycle did not achieve a normal blood loss and required surgery. 23

A comparison of the drugs used in all the controlled trials indicates that a norgestrel-releasing intrauterine device (IUD), 28,30 danazol, 20,28 and tranexamic acid 24,30 are most effective in reducing menstrual blood loss, while mefenamic acid, 20,28 the oral contraceptive pill and progestogens are usually less effective. A recent study has shown tranexamic acid to be more effective (54% reduction in blood loss) than mefenamic acid (20% reduction), whereas ethamsylate (a clotting agent) was ineffective. 31 (The hormone-releasing IUD is not registered for use in Australia or the United Kingdom as treatment for menorrhagia.) Danazol's serious side effects (menopausal symptoms and mild androgenic effects) make it unacceptable for long term use and it is also relatively expensive.Tranexamic acid has few side effects and offers the advantage of alleviating menstrual pain.

Surgery

Abdominal hysterectomy v. endometrial resection

Randomised controlled trials have been performed comparing abdominal hysterectomy with less invasive surgical intervention for menorrhagia. 32,33

Myomectomy

The number of abdominal myomectomies performed in Australia has been estimated at 1500 per year; most are for menorrhagia in women wishing to retain the uterus. 2 After myomectomy, recurrence rates of 5%-27%, retreatment rates of 10%, and fertility rates of 40%-59% have been reported. 37

Some abdominal myomectomies may be replaced by laparoscopic or laparoscopic-minilaparotomy procedures, as fibroids up to 14 cm in diameter in uteri up to the size of a uterus in a 24 weeks' pregnant woman have been removed by these methods. 29,38 The safety of the laparoscopic technique has been established, with the only serious complication among 214 patients in three studies being one postoperative haemorrhage requiring reoperation. 29,38,39

Abdominal v. laparoscopic myomectomy

Myoma reduction has been performed by laser or electro coagulation. A volume reduction varying from 10% to 80% has been achieved with fibromyoma up to 10 cm in diameter. Follow-up so far has been limited to three years and there has been little or no regrowth. 37,41 Results of further studies may establish its role in the treatment of menorrhagia.

Hysterectomy

Compared with abdominal hysterectomy, vaginal hysterectomy is associated with less pain and morbidity, shorter hospital stays and faster recovery periods. 42 However, analysis of Australian hospital morbidity data indicates that at least some of these benefits do not always accrue. 2 It is more difficult to perform and its use to date for menorrhagia and, in particular, myomas is limited. Only 25% of hysterectomies are performed vaginally in Australia. 2

Techniques for laparoscopic hysterectomy are still developing. 43,44 Results indicate that, compared with abdominal hysterectomy, postoperative pain is reduced and hospital stays (one to four days) and recovery periods (one to four weeks) are shorter. A meta-analysis of 29 reports involving 3189 patients having laparoscopic hysterectomy 45 showed lower febrile morbidity and incidence of blood transfusion, but similar serious complication rates, to both vaginal and abdominal hysterectomies. Seven controlled trials comparing laparoscopic with abdominal procedures showed reduced time in hospital, shorter convalescence and similar complication rates. 45,46 Like vaginal hysterectomy, laparoscopic hysterectomy, with its reduced recovery period, does benefit patients, their families and employers.

In conclusion, the diversity of possible surgical treatments indicates the need for flexibility in choosing techniques to resolve an individual patient's problem, and the possible advantage for gynaecologists to learn the new hysteroscopic and laparoscopic techniques for removal of the endometrium, polyps, myomas, adenomyomas and the uterus (Box 4).

References

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Author's details

Melbourne Gynoscopy Centre, Melbourne, VIC.
Carl E Wood, FRACOG, Professor, Department of Obstetrics and Gynaecology, Monash University.
Reprints: Professor C E Wood, Melbourne Gynoscopy Centre, 284 High Street, Ashburton, VIC 3147.

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