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Encyclopedia > Menorrhagia
Menorrhagia
Classification & external resources
ICD-9 Premenopausal menorrhagia 627.0

Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the womb. Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrhea). The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... Menstrual cycle. ... The endometrium is the inner membrane of the mammalian uterus. ... The womb is the major female reproductive organ of most mammals, including humans. ... Dysmenorrhea (or dysmenorrhoea), cramps or painful menstruation, involves menstrual periods that are accompanied by either sharp, intermittent pain or dull, aching pain, usually in the pelvis or lower abdomen. ...

Contents

Definition

A normal menstrual cycle is 21-35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. A blood loss of greater than 80 ml or lasting longer than 7 days constitutes menorrhagia (also called hypermenorrhea). In practice this is not usually directly measured by patients or doctors. Menorrhagia also occurs at predictable and normal (usually about 28 days) intervals, distinguishing it from menometrorrhagia, which occurs at irregular and more frequent intervals. It is possible to estimate the amount of bleeding by the number of tampons or pads a woman uses during her period. As a guide a regular tampon fully soaked will hold about 5ml of blood.


Complications

Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia. Symptoms attributable to the anemia may include tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration. Anemia (AmE) or anæmia (BrE), from the Greek () meaning without blood, is a deficiency of red blood cells (RBCs) and/or hemoglobin. ...


Etiology

Usually no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. A brief overview of causes is given below, followed by a more formal medical list based on the nature of the menstrual cycle experienced.


Disorders of coagulation

With the shedding of the endometrial lining's blood vessels, normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Coagulation is a complex process by which blood forms solid clots. ... A 250 ml bag of newly collected platelets. ... Idiopathic thrombocytopenic purpura (ITP) is the condition of having a low platelet count (thrombocytopenia) of no known cause (idiopathic). ... Coagulation is a complex process by which blood forms solid clots. ... Von Willebrands disease (vWD) is the most common hereditary coagulation abnormality described in humans. ... An anticoagulant is a substance that prevents coagulation; that is, it stops blood from clotting. ... Warfarin (also known under the brand names of Coumadin, Jantoven, Marevan, and Waran) is an anticoagulant medication that is administered orally or, very rarely, by injection. ...


Excessive build up in endometrial lining

Periods soon after the onset of menstruation in girls (the menarche) and just before menopause may in some women be particularly heavy. Hormonal disorders involving the ovaries-pituitary-hypothalamus (the 'ovarian endocrine axis') account for many cases, and hormonal-based treatments may regulate effectively. Menarche (IPA: ) is the first menstrual period, or first menstrual bleeding. ... Menopause is the physiological cessation of menstrual cycles associated with advancing age in women. ...


The lining of the womb builds up naturally under the hormonal effects of pregnancy, and an early spontaneous miscarriage may be mistaken for a heavier than normal period. Miscarriage or spontaneous abortion is the natural or accidental termination of a pregnancy at a stage where the embryo or the fetus is incapable of surviving, generally defined at a gestation of prior to 20 weeks. ...


Irritation of the endometrium may result in increased blood flow, e.g. from infection (acute or chronic pelvic inflammatory disease) or the contraceptive intrauterine device (note the distinction from the IntraUterine System which is used to treat this condition). Pelvic inflammatory disease (or disorder) (PID) is a generic term for infection of the female uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. ... An intra-uterine device (intra meaning within, and uterine meaning of the uterus) is a birth control device also known as an IUD or a coil (this colloquialism is based on the coil-shaped design of early IUDs). ... The IntraUterine System or IUS is an IntraUterine Device (IUD or coil) that has a coating of levonorgestrel (a progesterone) on its shaft, rather than the traditional copper wire. ...


Fibroids in the wall of the womb sometimes can cause increase menstrual loss if they protrude into the central cavity and so thereby increase endometrium's surface area. Uterine fibroids (leiomyomata, singular leiomyoma) are the most common neoplasm in females, and may affect about 25 % of white and 50% of black women during the reproductive years. ...


Abnormalities of the endometrium such as adenomyosis (so called "internal endometriosis") where there is extension into the wall of the womb gives rise to enlarged tender uterus. Note, true endometriosis is a cause of pain (dysmenorrhoea) but usually not alteration in menstrual blood loss. Adenomyosis is a medical condition characterized by the presence of ectopic endometrial tissue (the inner lining of the uterus) within the myometrium (the thick, muscular layer of the uterus). ... Dysmenorrhea (or dysmenorrhoea), cramps or painful menstruation, involves menstrual periods that are accompanied by either sharp, intermittent pain or dull, aching pain, usually in the pelvis or lower abdomen. ...


Endometrial carcinoma (cancer of the uterine lining) usually causes irregular bleeding, rather than the cyclical pattern of menorrhagia. Bleeding in between periods (intermenstrual bleeding or IMB) or after the menopause (postmenopausal bleeding or PMB) should always be considered suspicious. Endometrial cancer involves cancerous growth of the endometrium (lining of the uterus). ...


Consideration by nature of the menstrual cycle

  • Excessive menses but normal cycle:
  • Short cycle (<21 days) but normal menses (epimenorrhoea or polymenorrhoea). These are always anovulatory cycles due to hormonal disorders.
  • Short cycle and excessive menses (epimenorrhagia) due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours.
  • Excessive menses and long intervals.
    • Anovular ovarian disorder due to prolonged oestrogen production.
    • This may occur following prolonged continuous courses of the combined oral contraceptive pill (e.g. where several packets are taken without a withdrawal gap in order to defer menstruation).

Uterine fibroids (leiomyomata, singular leiomyoma) are the most common neoplasm in females, and may affect about of 25 % of white and 50% of black women during the reproductive years. ... Dysfunctional Uterine Bleeding (DUB) is the most common cause of functional abnormal uterine bleeding, which is abnormal genital tract bleeding based in the uterus and found in the absence of demonstrable organic pathology. ... Pelvic inflammatory disease (or disorder) (PID) is a generic term for infection of the female uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. ... The anovulatory cycle is a menstrual cycle characterized by varying degrees of menstrual intervals and the absence of ovulation and a luteal phase. ... The combined oral contraceptive pill, often referred to as the Pill, is a combination of an estrogen (oestrogen) and a progestin (progestogen), taken by mouth to inhibit normal fertility. ...

Differential Diagnosis

  • Pregnancy complications:
    • Ectopic pregnancy
    • Incomplete abortion
    • Miscarriage
    • Threatened abortion
  • Nonuterine bleeding:
    • Cervical ectropion/erosion
    • Cervical neoplasia/polyp
    • Cervical or vaginal trauma
    • Condylomata
    • Atrophic vaginitis
    • Foreign bodies
  • Pelvic inflammatory disease (PID):
    • Endometritis
    • Tuberculosis
  • Hypothyroidism

Miscarriage or spontaneous abortion is the natural or accidental termination of a pregnancy at a stage where the embryo or the fetus is incapable of surviving, generally defined at a gestation of prior to 20 weeks. ...

Risk Factors

  • Obesity
  • Anovulation
  • Estrogen administration (without progestogens)
  • Prior treatment with progestational agents or oral contraceptives increases the risk of endometrial atrophy, but decreases the risk of endometrial hyperplasia or neoplasia

ICD-9 codes

Classification of some causes
Cause ICD-9 code
Polyp of corpus uteri 621.0
Endometrial cystic hyperplasia 621.3
Other specified disorders of uterus, NEC 621.8
Excessive or frequent menstruation 626.2
Puberty bleeding 626.3
Irregular menstrual cycle 626.4
Metrorrhagia 626.6
Disorders of menstruation and other abnormal bleeding
from female genital tract, other
626.8
Premenopausal menorrhagia 627.0
Postmenopausal bleeding 627.1

Investigation

  • Pelvic and rectal examination
  • Pap smear
  • Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.[1]
  • Endometrial biopsy to exclude endometrial cancer or atypical hyperplasia
  • Hysteroscopy

Treatment

Where an underlying cause can be identified, treatment may be directed at this. Clearly heavy periods at the start and end of a women's reproductive years may settle spontaneously (the menopause being the cessation of periods).


If the degree of bleeding is mild, all that may be sought by the woman is the reassurance that there is no sinister underlying cause. If anaemia occurs then iron tablets may be used to help restore normal hemoglobin levels. Treatment may be given for a fixed period of time to replenish the body stores. Alternatively therapy may be continued long-term, often in a cyclical regimen on the days of menstruation. General Name, Symbol, Number iron, Fe, 26 Chemical series transition metals Group, Period, Block 8, 4, d Appearance lustrous metallic with a grayish tinge Standard atomic weight 55. ... Structure of hemoglobin. ...


The condition is often be treated with hormones, particularly as dysfunctional uterine bleeding commonly occurs in the early and late menstrual years when contraception is also sought. Usually oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System may be used. Fibroids may respond to hormonal treatment, else require surgical removal. Birth control is the practice of preventing or reducing the probability of pregnancy without abstaining from sexual intercourse; the term is also sometimes used to include abortion, the ending of an unwanted pregnancy, or abstinence. ... Progesterone Only Pill (POP) are contraceptive pills that only contain progesterone (or, as used in the USA, the term Progestin for synthetic progesterones). ... This article is about the contraceptive injection. ... Progesterone is a C-21 steroid hormone involved in the female menstrual cycle, pregnancy (supports gestation) and embryogenesis of humans and other species. ... The IntraUterine System or IUS is an IntraUterine Device (IUD or coil) that has a coating of levonorgestrel (a progesterone) on its shaft, rather than the traditional copper wire. ...


Anti-inflammatory medication has previously been used, although it has a greater effect on dysmenorrhoea excess pain than on the heaviness of the period (typically 30% reduction in flow). More effective is the use of tranexamic acid tablets that may reduce loss by up to 50%. This may be combined with hormonal medication previously mentioned. Anti-inflammatory refers to the property of a substance or treatment that reduces inflammation. ... Tranexamic acid (commonly marketed as Cyclokapron) is often prescribed for excessive bleeding. ...


A definitive treatment for menorrhagia is to perform hysterectomy (removal of the uterus). This historically has been associated with issues of male domination within medicine and patient's subservient roles. The risks of the procedure have been reduced with measures to reduce the risk of deep vein thrombosis after surgery, and the switch from the front abdominal to vaginal approach greatly minimising the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids may be dealt with by local removal (myomectomy). A further surgical technique is endometrial ablation (destruction) by the use of applied heat (thermoablation). A non-surgical approach has been the introduction and use of the IntraUterine System. This article or section is in need of attention from an expert on the subject. ... This article is about Deep-vein thrombosis. ... Myomectomy refers to the surgical removal of uterine fibroids. ... Endometrial ablation is a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a womans uterus. ... The IntraUterine System or IUS is an IntraUterine Device (IUD or coil) that has a coating of levonorgestrel (a progesterone) on its shaft, rather than the traditional copper wire. ...


In the UK the use of hysterectomy for menorrhagia has been almost halved between 1989 and 2003[2]. This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS[3][4] which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery[5].


Treatment Options

NOTE: Management of bleeding in pregnancy requires gynaecology referral and potential hospital admission especially if bleeding does not stop or is substantial and surgical intervention is required.


Blood transfusions may be required for blood loss resulting in compromised hemodynamic stability.


Treatment options include pharmaceutical or surgical and radiological options:

Pharmaceutical treatments

These have been ranked by the UK's National Institute for Health and Clinical Excellence:[1] The National Institute for Health and Clinical Excellence or NICE is an agency of the National Health Service in the United Kingdom. ...

Surgical and radiological treatments
  • Dilation and curettage (D&C) is no longer performed for cases of simple menorrhagia, having a reserved role if a spontaneous abortion is incomplete
  • Endometrial ablation
  • Uterine artery embolisation (UAE)
  • Hysteroscopic myomectomy to remove fibroids over 3 cm in diameter
  • Hysterectomy

The IntraUterine System or IUS is an IntraUterine Device (IUD or coil) that has a coating of levonorgestrel (a progesterone) on its shaft, rather than the traditional copper wire. ... Tranexamic acid (commonly marketed as Cyclokapron) is often prescribed for excessive bleeding. ... Wikipedia does not yet have an article with this exact name. ... The combined oral contraceptive pill, often referred to as the Pill, is a combination of an estrogen (oestrogen) and a progestin (progestogen), taken by mouth to inhibit normal fertility. ... Norethisterone (or norethindrone) (or 19-nor-17α-ethynyltestosterone) is a molecule used in some combined oral contraceptive pills and in some progestogen only pills. ... This article is about the contraceptive injection. ... Goserelin is an injectable luteinising hormone-releasing hormone analogue (LHRHa). ... Endometrial ablation is a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a womans uterus. ... Wikipedia does not have an article with this exact name. ... In medicine, an embolism occurs when an object (the embolus, plural emboli) migrates from one part of the body (through circulation) and cause(s) a blockage (occlusion) of a blood vessel in another part of the body. ... Myomectomy refers to the surgical removal of uterine fibroids. ...

References

Look up who in Wiktionary, the free dictionary. ... The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, is recognized as the leading United States agency for protecting the public health and safety of people. ... The Johns Hopkins Hospital is a teaching hospital in Baltimore, Maryland. ...

Footnotes

  1. ^ a  CG44 Heavy menstrual bleeding: Understanding NICE guidance (PDF). National Institute for Health and Clinical Excellence (UK) (24 January 2007).
  2. ^  Reid P, Mukri F (Apr 23 2005). "Trends in number of hysterectomies performed in England for menorrhagia: examination of health episode statistics, 1989 to 2002-3.". BMJ 330 (7497): 938-9. PMID 15695496. 
  3. ^  Hurskainen R, Teperi J, Rissanen P, Aalto A, Grenman S, Kivelä A, Kujansuu E, Vuorma S, Yliskoski M, Paavonen J (Mar 24 2004). "Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up.". JAMA 291 (12): 1456-63. PMID 15039412. 
  4. ^  Istre O, Trolle B (Aug 2001). "Treatment of menorrhagia with the levonorgestrel intrauterine system versus endometrial resection.". Fertil Steril 76 (2): 304-9. PMID 11476777. 
  5. ^  Stewart A, Cummins C, Gold L, Jordan R, Phillips W (Jan 2001). "The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review.". BJOG 108 (1): 74-86. PMID 11213008. 
  6. ^  Feig, Robert L. and Nicole C. Johnson.. First Aid for the Obstetrics and Gynecology Clerkship. ISBN ISBN 0-07-136423-4. 

  Results from FactBites:
 
Menorrhagia - Wikipedia, the free encyclopedia (1133 words)
Menorrhagia is an abnormally heavy and prolonged menstrual period.
Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the womb.
A definitive treatment for menorrhagia is to perform hysterectomy removal of the womb.
Diagnose-Me: Condition: Menorrhagia (Heavy Periods) (3021 words)
Menorrhagia is the term for excessive menstrual bleeding i.e.
Chronic menorrhagia and PMS is usually the result of deficient progesterone secretion or constant adipose-released estradiol from obesity or recent substantial weight loss.
Although bleeding time and prothrombin levels in women with menorrhagia are typically normal, the use of vitamin K (often in the form of chlorophyll) does have limited research support.
  More results at FactBites »

 
 

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