Menorrhagia- Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Excessive amount or duration of menstrual flow, at more or less regular intervals. Flow ≥80 mL per cycle, compared to normal average 30–40 mL (1,2).
- Distinguishable from but may overlap with:
- Metrorrhagia: Irregular or frequent flow, noncyclic
- Menometrorrhagia: Frequent, excessive, irregular flow (menorrhagia plus metrorrhagia)
- Polymenorrhea: Frequent flow, cycles of 21 days or fewer
- Intermenstrual bleeding: Bleeding between regular menses
- Dysfunctional uterine bleeding (DUB): Abnormal endometrial bleeding of hormonal cause and related to anovulation
- System(s) affected: Reproductive
- ∼30% of women complain of excessive bleeding at some point (1).
- Predominant sex: Female only
- Predominant age:
- Menarche to menopause; ∼50% of cases occur in patients >40 years old
- Dysfunctional bleeding is fairly common in adolescence and near menopause.
- In adolescence, irregular bleeding due to anovulation and immaturity of the hypothalamic-pituitary-ovarian axis is common.
Genital bleeding before puberty can result from trauma, foreign bodies, vaginal infection, or exogenous hormone administration.
Bleeding in pregnancy is not menorrhagia. Complications of pregnancy or cervical/vaginal lesions should be considered.
True menorrhagia cannot occur after menopause. However, genital atrophy as well as uterine and ovarian cancers may be associated with vaginal bleeding in the elderly.
- Estrogen administration (±progestin)
- Prior treatment with progestational agents or oral contraceptives increases risk of endometrial atrophy, but decreases risk of endometrial hyperplasia or neoplasia.
Periodic Pap smears and pelvic examinations at appropriate intervals based on age and risk factors
- Endometrial proliferation/excess/hyperplasia:
- Anovulation, oligo-ovulation
- Ovarian tumor
- Prolonged estrogen, progestin, or oral contraceptive administration
- Polycystic ovarian syndrome
- Local factors:
- Endometrial atrophy, postmenopause
- Abnormal endometrial prostaglandin levels
- Endometrial polyps
- Endometrial neoplasia
- Uterine myomata (fibroids)
- Intrauterine device (IUD)
- Uterine sarcoma
- Coagulation disorders:
- Thrombocytopenia, platelet disorders
- von Willebrand disease, factor deficiencies
- Ingestion of aspirin/acetylsalicylic acid or anticoagulants
- Renal failure/dialysis
Commonly Associated Conditions
Metrorrhagia, menometrorrhagia, androgenic disorders
- Excessive menstrual flow is defined subjectively and varies greatly from woman to woman.
- Useful features:
- Bleeding substantially heavier than usual flow
- Bleeding lasting >7 days
- Flow associated with significant clots
- Symptoms that suggest cycles are ovulatory:
- Regular menstrual interval
- Midcycle pain (mittelschmerz)
- Premenstrual symptoms: Breast soreness/tenderness, mood changes
- Abdominal pain or cramps at other times of the cycle may be associated with structural causes:
- Ovarian tumors
- Hirsutism, acne, or obesity may accompany chronic anovulation.
- Pelvic/rectal examination to detect/exclude other causes of bleeding:
- Cervical or vaginal bleeding
- Pelvic or adnexal masses
- Signs of pelvic infection
Diagnostic Tests & Interpretation
Initial lab tests
- Pregnancy test: Exclude pregnancy first.
- CBC to assess severity of blood loss and to rule out thrombocytopenia and leukemia (2)
- In selected cases:
- TSH test
- Coagulation screen, with follow-up testing if screen is abnormal
- Creatinine, BUN
- Serum progesterone: 5–20 ng/mL (15.9–63.6 nmol/L) in luteal phase, <1 ng/mL (<3.18 nmol/L) in follicular phase or anovulatory cycle
- Transvaginal ultrasonography can help distinguish bleeding due to atrophy from bleeding caused by hyperplasia, polyps, or myomas.
- Ultrasonography to evaluate adnexal masses or myomas suspected from pelvic exam.
- CT is used in investigation of potentially malignant pelvic masses.
- Endometrial biopsy detects hyperplasia, dysplasia, or atrophy. If done before expected menses, it may also help confirm the diagnosis of anovulation or luteal phase defect.
- After age 35–40 endometrial carcinoma is significant cause of bleeding. Obtain endometrial sampling before attempting hormonal treatment (3)[C].
- Vary with etiology. In ∼50% of cases, no uterine pathology is found (1).
- Progestins used before endometrial biopsy may cause decidualization and obscure correct diagnosis.
- Pregnancy complications:
- Threatened abortion
- Incomplete abortion
- Ectopic pregnancy
- Nonuterine bleeding:
- Cervical ectropion/erosion
- Cervical neoplasia/polyp
- Cervical or vaginal trauma/foreign body
- Atrophic vaginitis
- Pelvic inflammatory disease:
- For acute control of severe bleeding:
- Estrogen, conjugated (Premarin): 25 mg IV q4h up to 6 doses or 10–20 mg/d p.o. in 4 divided doses until bleeding abates (3)[C]
- For less severe bleeding or after control of acute bleeding has been achieved:
- Medroxyprogesterone acetate (Provera): 10–30 mg/d for 5–10 days
- Any combination oral contraceptive (i.e., usually a high-dose oral contraceptive) 1 tablet q.i.d. for 5–7 days
- To prevent heavy bleeding in subsequent cycles:
- Medroxyprogesterone acetate: 5–30 mg/d for 10 days per month
- Usual cyclic dose of a combination oral contraceptive (3)[C]
- Nonsteroidal prostaglandin-synthetase inhibitors (e.g., naproxen, mefenamic acid, ibuprofen) can reduce blood loss ∼25% with ovulatory cycles and reduce dysmenorrhea (4)[B].
- Tranexamic acid (Cyklokapron), a plasminogen activation inhibitor, 2 g/d orally is equally or more effective than medroxyprogesterone 10 mg twice daily (5)[B].
- Norethindrone acetate (Aygestin): 2.5–10 mg/d for 10–21 days per month
- Levonorgestrel intrauterine system (Mirena IUD) can reduce blood loss >90% (4)[B].
- Danazol and GnRH agonists are also effective therapies, but more likely to have adverse side effects. Mifepristone (RU-486) has been used experimentally (1).
Nausea and vomiting are common from IV estrogen; antiemetics are helpful.
- Hysterectomy when indicated to treat coexisting conditions (myomas, endometrial dysplasia) or for bleeding unresponsive to other measures (1,6).
- Endometrial ablation by laser, electrosurgical, microwave, or thermal means is a conservative alternative to hysterectomy, but long-term control of bleeding and patient satisfaction are lower than with hysterectomy (1,7)[A].
- Most cases can be managed as outpatient in office or emergency department.
- Rule out pregnancy complications and nonuterine bleeding.
- Treat severe or life-threatening bleeding acutely:
- Circulatory support, transfusion if necessary
- IV estrogen
- Curettage if necessary
- Hysterectomy in extreme case
- Bleeding leading to orthostatic hypotension
- Hematocrit <25%
Proceed to identify underlying cause of bleeding and treat to prevent recurrence:
- Hormonal therapy
- Dilatation and curettage for cases that fail to respond to hormone therapy
- Consider endometrial ablation or hysterectomy in persistent cases in which fertility is not a concern.
- Specific treatment for neoplasia, polyps, systemic disease
- Patients in whom fertility is a consideration may also need appropriate treatment for anovulation, endometriosis, and myomas.
- Varies with cause of bleeding
- Medical treatment of hyperplastic/dysplastic endometrium should be followed by repeat biopsy to confirm that histologic structure has returned to normal.
Iron supplementation may help correct for increased blood loss.
Information about side effects of medications should be provided.
- Varies with cause of bleeding
- Most patients whose condition results from hormonal causes will respond to hormonal manipulation.
- Estrogen may precipitate acute intermittent porphyria or cholestatic jaundice in susceptible patients.
1. Oehler MK, Rees MC. Menorrhagia: an update. Acta Obstet Gynecol Scand. 2003;82:405–22.
2. Siegel JE. Abnormalities of hemostasis and abnormal uterine bleeding. Clinical Obstetrics & Gynecology. 2005;48:284–94.
3. Management of anovulatory bleeding. ACOG Practice Bulletin 14, March 2000, reaffirmed 2009.
4. Reid PC, Virtanen-Kari S. Randomised comparative trial of levonorgestrel intrauterine system and mefenamic acid for the treatment of idiopathic menorrhagia. BJOG. 2005;112:1121–5.
5. Kriplani A, Kulshrestha V, Agarwal N, et al. Role of tranexamic acid in management of dysfunctional uterine bleeding in comparison with medroxyprogesterone acetate. J Obstet Gynaecol. 2006;26:673–8.
6. Showstack J, Lin F, Learman LA, et al. Randomized trial of medical treatment versus hysterectomy for abnormal uterine bleeding: resource use in the Medicine or Surgery (Ms) trial. Am J Obstet Gynecol.2006;194:332–8.
7. Practice Committee of American Society for Reproductive Medicine et al. Indications and options for endometrial ablation. Fertil. Steril. 2008;90:S236–40.
See Also (Topic, Algorithm, Electronic Media Element)
Amenorrhea; Abnormal Pap and Cervical Dysplasia; Cervical Malignancy; Cervical Polyps; Cervicitis, Ectropion, and True Erosion; Dysfunctional Uterine Bleeding; Dysmenorrhea; Menopause; Polycystic Ovarian Syndrome; Uterine Myomas
- 626.2 Excessive or frequent menstruation
- 626.3 Puberty bleeding
- 386692008 Menorrhagia (finding)
- 237125007 pubertal menorrhagia (finding)
- Menorrhagia is defined as excessive amount or duration of menstrual flow at more or less regular intervals and has a wide variety of potential causes.
- Pregnancy should be ruled out as part of the initial evaluation.
- Because endometrial carcinoma is a significant cause of bleeding in women over age 35, an endometrial biopsy to rule out endometrial carcinoma is recommended before using any hormonal treatments.
- Iron supplementation will help correct for increased blood loss while the underlying etiology is being identified and treated.