Menorrhagia: Current Management Approaches

Menorrhagia or heavy menstrual bleeding (HMB) is the most common gynecologic problem encountered in primary care. It wreaks havoc with quality of life, and can cause or contribute to anemia, fatigue, and anxiety. Its definition — excessive menstrual blood loss more than 80 mL per cycle — is usually applied subjectively, since women report any bleeding that seems heavy and interferes with activities of daily living.

In retail health clinics, practitioners may see women who report unpredictable menstrual frequency in cycles shorter than 21 days, unpredictable onset, periods of longer than 8 days, heavy bleeding, or breakthrough bleeding. Roughly 27% of women report 2 or more symptoms of HMB annually.

When assessing HMB, retail health care providers need to explore the patient’s menstrual history (eg cycle length and duration), the presence or absence of clotting, and the volume of sanitary products used. Irregular or inter-menstrual bleeding should heighten suspicion of uterine pathology. Asking patients to complete a pictoral blood assessment chart (which are available for free on the Internet) can help quantify blood loss in future cycles.

All women should be screened for anemia, and asked questions about the extent to which HMB interferes with activity. A frequent and good assessment question is, “How many days of work have you missed because of heavy bleeding?”

Pelvic examination, ultrasound scan, and laboratory diagnostics can rule out presence of many underlying uterine pathologies, including coagulopathy, ovulation dysfunction, or iatrogenic issues.

Women’s preference and fertility plans will dictate selection of treatment approaches.

Options include hormonal treatments, levonorgestrel-releasing intrauterine system (LNG-IUS), and combined hormonal contraceptives:

· Ulipristal acetate is an approved emergency contraceptive in the United States, and as a preoperative treatment for uterine fibroids in Europe. It has been used to decrease menstrual blood loss.

· Reductions in bleeding volume of 70% have been reported after LNG-IUS placement.

· Combined oral contraceptives reduce menstrual blood loss by thinning the endometrium, and inducing shorter, regular shedding of this tissue.

· Cyclical oral progestins in cycles of 3 weeks on, 1 week off, reduces blood loss by more than 60%, but many women experience intolerable adverse effects and unpredictable bleeding.

· Other options are available in women with contraindications to these drugs.

Research indicates that up to 20% of women with menorrhagia have inherited bleeding disorders (IBD), the most common of which is von Willebrand disease. This IBD occurs in just 1% of the overall population, but in 13% of women with HMB. IBD patients often respond to tranexamic acid or desmopressin alone or in combination with hormonal treatments. Again, the patient’s pregnancy plan will dictate choices. Moderate to serious cases of IBD are best referred to and managed by a specialist.

Patients who fail to respond to medication or prefer not to take it can be referred for endometrial ablation, and if that fails, hysterectomy.

Reference

Davies J, Kadir RA. Heavy menstrual bleeding: An update on management.Thromb Res.2017 Mar;151 Suppl 1:S70-S77.

Leissinger C, Becton D, Cornell C, et al. High-dose DDAVP intranasal spray (Stimate) for the prevention and treatment of bleeding in patients with mild hemophilia A, mild or moderate type 1 von Willebrand disease and symptomatic carriers of hemophilia A.Haemophilia.2001;7:258-266.

Yawn BP, Nichols WL, Rick ME. Diagnosis and management of von Willebrand disease: guidelines for primary care.Am Fam Physician. 2009;80:1261-1268.