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:
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Dilatation and curettage
Outpatient endometrial sampling
Hysteroscopy
Vaginal ultrasonography.
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 agematched 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 norgestrelreleasing 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
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Abdominal hysterectomy requires longer theatre times and six or seven days'
hospital stay, whereas endometrial resection (ablation) is a day-stay or
overnight procedure.
Abdominal hysterectomy has a higher complication rate (45%) compared with
transcervical endometrial resection (0-15%). Complications include uterine
perforation, fluid overload, haemorrhage and cervical stenosis.
Reported mortality rates for abdominal hysterectomy are two to five times
higher than those for endometrial resection (0.06%-0.16% v. 0.03%), and
major complication rates are five to twelve times higher (1%-2.5% v. 0.2%). 34
Resumption of normal activities after abdominal hysterectomy takes two to
three months versus two to three weeks for resection.
Endometrial resection results in 13%-64% of women having no menstrual
bleeding and 62%-77% having reduced menstrual loss.
After endometrial resection 6%-23% of women require reoperation for
continued bleeding, with the higher rates being reported in studies with a
longer follow-up. 32,33
The probability of requiring a hysterectomy four years after endometrial
resection has been estimated to be 12%. 35
Some form of sterilisation or contraception is needed after endometrial
resection. Pregnancy is unlikely, but if it occurs the risk of complications is
higher.
Hysterectomy is preferable if the patient has a large uterus, severe
endometriosis, a desire for amenorrhoea or certain cure, or there is an
increased risk of uterine cancer (family history, marked obesity, polycystic
ovaries and diabetes).
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Endometrial resection can be used if a woman is unfit for hysterectomy. It also
avoids possible ovarian dysfunction and the psychological effects of
hysterectomy.
Endometrial resection has a 47% cost advantage over hysterectomy because of
shorter theatre time and hospital stay, but the cost advantage diminishes with
time to 29% because of the need for repeat surgery. 36
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 laparoscopicminilaparotomy 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
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The average hospital stay for abdominal myomectomy is four to five days,
compared with one to three days for the laparoscopic procedure. 29,40
The cost of laparoscopic myomectomy ($2217) is lower than that of
abdominal myomectomy ($3825). 2
Laparoscopic myomectomy involves a shorter hospital stay, with probable
associated advantages of reduced pain, reduced risk of wound complications,
earlier return to normal activity, and reduced costs. 40
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).
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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.