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Gold, incentives and meh

Effective management of menorrhagia

Management of menorrhagia has changed and effective medical

and surgical therapies exist that are now being more widely used – Dr Andrew Prentice examines the latest evidence

What this article covers

lWhat causes menorrhagia?

lWhich treatments have proved to be effective?

lWhat is the role of surgery in current management?

There is no doubt that the clinical problem of menorrhagia is a significant drain on health care resources. Surgical management by hysterectomy, myomectomy, resection and ablation uses a large amount of resource, with one in five women in the UK being subjected to a hysterectomy by the end of their reproductive life. But even more important is the impact the complaint has on primary care.

In the UK 5 per cent of women of reproductive age will seek help annually for the subjective complaint of heavy periods, although as many as one-third consider their menstrual loss to be excessive1.

Population studies suggest 10 per cent of women actually have periods that objectively could be considered as heavy, with measured losses in excess of 80mL per menses.

The clinical problem, however, is not the management of the patient with an objectively heavy loss but rather the patient who subjectively complains of heavy periods. Confirmation of the clinical problem is difficult from the history alone, although a number of questions may highlight the extent of the problem (see table below).

In essence we are treating the patient's perception that her periods are a problem, whether they are actually heavy or not. It may be that the patient may not be at all anxious about her menstrual loss but uses this symptom to seek reassurance that there are no other genital tract problems, in particular malignancy.

In the majority of cases the menorrhagia is associated with no specific underlying organic pathology, that is dysfunctional uterine bleeding.

But on close study these women have haemostatic and biochemical abnormalities within the endometrium itself, including increased fibrinolytic activity and prostaglandin production within the endometrium2,3. These observations provide the rational basis for first-line therapy.

It should be noted that in the majority of women menorrhagia is associated with regular periods. The significance of this is that the regular cycle confirms that there is no endocrine abnormality, and in these cases there is little role for hormonal therapy except when it is used to either impose or abolish a menstrual cycle.

Investigation and referral

It is often forgotten why we investigate menorrhagia. Other than the fact that the symptom itself is very distressing for the woman, there are two valid reasons for further investigation: identifying iron deficiency anaemia, and the possibility that endometrial cancer may be present.

All women presenting with heavy periods should have an assessment of their haemoglobin. But not all women require an assessment of endometrial histology because the incidence of endometrial cancer in the pre-menopausal woman, and in the under-40s in particular, is very low. Referral for endometrial assessment should follow the guidelines set out by the Royal College of Obstetricians and Gynaecologists.

Other investigation is rarely warranted4. As stated previously, menorrhagia is rarely the consequence of an endocrine dysfunction and therefore there is no justification for the routine assessment of oestradiol and gonadotrophins or thyroid function.

Ultrasound examination of the pelvis may be a useful investigation but is not required in all cases. Its use should be restricted to further evaluate the patient where the uterus is enlarged or an adnexal mass is detected on bimanual examination.

Investigation of haemostatic disorders such as von Willebrand's disease should be restricted to patients with specific indications.

First-line management

The choice of first-line therapy in women presenting with menorrhagia should consider:

l the likely underlying cause

l an assessment of contraceptive need

l additional symptoms, for example, dysmenorrhoea; and

l specific contraindications.

For the majority of patients the clinical diagnosis will be dysfunctional uterine bleeding and, as stated previously, the underlying abnormalities will be in the local fibrinolytic system or prostaglandin metabolism within the endometrium.

Rational management is to treat the likely underlying cause. For most women first-line management should be treatment with the anti-fibrinolytic tranexamic acid 1g three or four times daily5,6.

Tranexamic acid should not be used in women with a history of thrombo-embolic disease, and caution should be taken to exclude any predisposition to thrombo-embolic problems in women with a strong family history. An alternative for those women for whom anti-fibrinolytic therapy is contraindicated, or for whom dysmenorrhoea is a significant symptom, is the use of a NSAID such as mefenamic acid or ibuprofen7,8. However, it should not be forgotten that NSAIDs are contraindicated in patients with renal impairment.

These non-hormonal first-line therapies are very effective. Tranexamic acid has been shown to reduce blood loss by about one half, while the NSAIDs have been reported to reduce blood loss by between a quarter and a third.

One advantage of both these therapies is that they are taken only at the time of menstruation. Tranexamic acid also has a rapid mode of action with a reduction in menstrual loss within two to three hours.

Role of hormonal therapy

One of the most common therapies for menorrhagia is the progestagens (principally norethisterone) used in the luteal phase of the menstrual cycle. However, these have been shown to be ineffective or unhelpful5.

Systemic progestagens are an effective treatment, but only when used in higher doses and for three weeks out of four, or used locally in the form of the Mirena IUS9.

Progestagens used in this cyclical manner are useful when cycle control is also an issue, but an alternative approach is to use a low-dose combined oral contraceptive (COC).

Therapy and contraception

The majority of patients who complain of menorrhagia are in the late fourth or fifth decade of life. For many of these women their families are complete, and a permanent form of contraception has been sought. There are those for whom contraception is still required, but for many there is a reluctance to consider hormonal contraceptives and in others their use may be contraindicated as a consequence of smoking habits or body habitus.

Nevertheless, many women at this time of life do not wish to contemplate a further pregnancy with its increased risks for both mother and baby.

The complaint of menorrhagia therefore provides an opportunity to review contraceptive needs as well as treating the presenting complaint.

It is well-recognised that traditional copper IUCDs may be associated with increased menstrual blood loss. Often the immediate response has been to treat this problem by removing the IUCD, but the excessive loss may also be treated with non-hormonal therapies4.

Alternatively, the IUCD could be replaced

with a medicated IUS. The Mirena IUS consists of a T-shaped IUCD frame with the coil of copper replaced by a slow-release reservoir of the progestogen levonorgestrel.

The slow release of hormone, at levels systemically less than those of the progestogen-only pill, acts directly on the endometrium. The end result is that the endometrium becomes inactive and thin with consequent amenorrhoea in the majority of women.

This side-effect of amenorrhoea is not always desirable in women wishing to have contraception, and experience from contraceptive trials has shown that many women request removal of the IUS for this reason.

In women with menorrhagia, however, this is a positive benefit and the side-effect most likely to cause problems is irregular bleeding and/or spotting, which is most likely to last for three months, but may persist for as long as six months.

Careful counselling is required to prevent requests for early removal, as this reduces the cost-effectiveness of this form of therapy, which may otherwise last for five years.

It is well-recognised by both doctors and patients that the withdrawal bleed on the COC is less heavy than normal menstruation. In the Netherlands the COC is considered to be a first-line therapy for menorrhagia, but in the UK both doctors and patients seem reluctant to consider the non-contraceptive benefits of the COC.

With the exception of smokers and the obese, there is no reason why women over the age of 35, who have no other contraindications, should not use this effective form of therapy.

Surgical therapy

There have been many advances in the surgical management of menorrhagia in the last two decades. Hysterectomy remains the gold standard, and it is associated with a 100 per cent reduction in menstrual loss and high rates of satisfaction.

Endometrial resection and ablation using electro-diathermy and laser have provided an alternative minimally invasive technique, and may be suitable for many women.

When they were introduced it was felt that their adoption would lead to a reduction in hysterectomy rates. However, this has not been the case and total operative intervention rates have in fact risen.

There is now an increasing number of second-generation ablative techniques using a variety of energy modalities, including diathermy, hot water, laser and microwave. It is likely that the next decade will see the widespread use of these techniques in the outpatient setting.

Conclusion

The management of menorrhagia has changed. Effective medical therapies exist and are now being more widely and effectively used. Surgical options are no longer confined to hysterectomy, and the threshold for surgery may have dropped.

Andrew Prentice is senior lecturer/consultant gynaecologist, The Rosie Hospital, Cambridge

Questions to ask in history taking

•Frequency of changing sanitary protection

•Requirement to change sanitary protection overnight

•Need to use double protection

•Flooding

•Passage of clots

•Interference with lifestyle, time off work etc

Take-home points

•Ten per cent of women have periods that objectively could be considered as heavy. The clinical problem, however, is not the management of the patient with an objectively heavy loss, but rather the patient who subjectively complains of heavy periods.

•In the majority of cases the menorrhagia is associated with no specific underlying organic pathology and is associated with regular periods.

•All women with heavy periods require haemoglobin assessment. Not all women require assessment of endometrial histology as the incidence of endometrial cancer in the pre-menopausal woman, particularly those under 40, is very low.

•For most women first-line management is tranexamic acid 1g three or four times daily. If this therapy is contraindicated, or when dysmenorrhoea is a significant symptom, a NSAID is used.

•A common, but ineffective, therapy for menorrhagia is the progestagens used in the luteal phase of the cycle. Systemic progestagens are effective, but only in higher doses and for three weeks out of four, or used locally as a Mirena IUS.

•With the exception of smokers and the obese, there is no reason why women over the age of 35, who have no other contraindications, should not use the COC as therapy.

•Surgically, hysterectomy remains the gold standard. Endometrial resection and ablation using electro-diathermy and laser is an alternative.

References

1 Vessey MP et al. The epidemiology of hysterectomy: findings in a large cohort study. Br J Obstet Gynaecol 1992;99:402-7

2 Dockery CJ et al. The fibrinolytic enzyme system in normal menstruation and excessive uterine bleeding and the effect of tranexamic acid.

Eur J Obstet Gynaecol Reprod Biol 1987;24:309-18

3 Smith SK et al. Prostaglandin synthesis in the endometrium of women with ovular dysfunctional uterine bleeding. Br J Obstet Gynaecol 1981;88:434-42

4 The initial management of menorrhagia. Evidence-Based Clinical Guidelines No.1 . London: Royal College of Obstetricians and Gynaecologists, 1998

5 Preston JT et al. Comparative study of tranexamic acid and norethisterone in the treatment of ovulatory menorrhagia. Br J Obstet Gynaecol 1995;102:401-6

6 Cooke I et al. Antifibrinolytics for heavy menstrual bleeding

(Cochrane Review). In: The Cochrane Library, Issue 1.

Oxford: Update Software, 1999

7 Bonnar J, Sheppard BL. Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid. BMJ 1996;313:579-82

8 Lethaby A et al. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding (Cochrane Review). In: The Cochrane Library,

Issue 1. Oxford: Update Software, 1999

9 Irvine GA et al. Randomised comparative trial of the levonorgestrel intrauterine system and norethisterone for the treatment of idiopathic menorrhagia. Br J Obstet Gynaecol 1998;105:592-8

Further information

www.rcog.org.uk

www.cochrane.org

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