INTRODUCTION — In a normal menstrual cycle, the average woman loses about 2 to 3 tablespoons (35 to 40 milliliters) of blood. However, some women lose much larger amounts of blood. Menorrhagia is the medical term for excessive or prolonged menstrual bleeding.
Women who lose 5 to 6 tablespoons (about 80 milliliters) of blood or more during their menstrual period are said to have menorrhagia. Losing a lot of blood during the menstrual period can cause medical problems and lifestyle issues. As an example, more than 50 percent of women with menorrhagia develop iron deficiency anemia (lower than normal amounts of red blood cells). Extremely heavy bleeding may interfere with a woman's life because of the frequent need to change pads or tampons and because heavy bleeding can cause painful menstrual cramps.
THE NORMAL MENSTRUAL CYCLE — Most women's menstrual cycle lasts between 24 and 35 days; the average is 28 days. During this time, the uterus, ovaries, hypothalamus, and pituitary gland follow a sequence of events that prepares the body for pregnancy. Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH), are made by the pituitary gland. These hormones stimulate the ovary to make two other hormones, progesterone and estrogen.
During the first half of the cycle, FSH stimulates a follicle to develop in one of the ovaries. This causes the estrogen level to rise, causing the lining of the uterus to grow and thicken (show figure 1). These events stimulate a risk in the LH level, which ultimately causes the follicle to release an egg from the ovary (called ovulation).
After ovulation, the ovary produces both estrogen and progesterone, which prepare the uterus for possible implantation and pregnancy. Progesterone also helps to "stabilize" the lining of the uterus, preventing abnormal bleeding. If pregnancy does not occur, estrogen and progesterone levels drop and the lining of the uterus is shed. The process of shedding is called the menstrual period. The menstrual blood contains blood as well as tissue from inside the uterus. Most women lose 2 to 3 tablespoons of blood over 3 to 7 days.
CAUSES — In women with menorrhagia, the sequence of events that leads to the menstrual period may be normal but bleeding is excessive because of an abnormal uterus (eg, due to abnormal growths) or because of a problem with blood clotting. In other women with menorrhagia, this sequence of events is abnormal because ovulation does not occur.
Anovulation — Anovulation occurs when a woman's ovaries fail to produce and release an egg (ovulate) once per month. Since the normal hormonal changes of ovulation do not occur, the lining of the uterus (called the endometrium) does not uniformly shed and regrow as in a normal menstrual cycle. Instead, excessive estrogen stimulates the lining of the uterus (endometrium) to continue growing and become thicker. Progesterone is not present at the usual levels, which causes the lining to shed irregularly, which results in heavy and/or prolonged bleeding.
Menorrhagia in adolescents is usually caused by anovulation. Anovulatory bleeding is also common before menopause (called perimenopause) and with some endocrine disorders, such as hypothyroidism and polycystic ovary syndrome. (See "Patient information: Menstrual cycle disorders (Absent and irregular periods)").
Bleeding tendency — Menorrhagia can result from conditions that prevent the blood from clotting normally. Some examples are von Willebrand disease, low platelet count or platelet dysfunction, and use of anticoagulants ("blood thinners") such as warfarin. (See "Patient information: Warfarin (Coumadin®)").
Uterine growths — When adult women experience menorrhagia, it is often due to a benign growth in the uterus. The most common growths are: Polyps, which are small grape-like growths of the lining of the uterus. Fibroids or leiomyomas, which are benign tumors involving the muscular walls of the uterus (myometrium) Adenomyosis, which refers to the growth of endometrial-like tissue within the muscular walls of the uterus
Rarely, cancer of the endometrium or myometrium can cause menorrhagia.
SIGNS AND SYMPTOMS — Women with menorrhagia typically have one or more of the following: Need to change pads/tampons more frequently than every three hours or use more than 21 pads/tampons during a period Need to use both pads and tampons to absorb menstrual flow Need to change pads or tampons during the night to absorb menstrual flow Pass blood clots larger than 1 inch Iron-deficiency anemia
DIAGNOSIS — If a healthcare provider suspects menorrhagia based on the woman's description of her bleeding, he or she will try to determine the cause by performing a medical history and physical examination. The physical examination is done to look for signs of bleeding elsewhere in the body, which could indicate a bleeding disorder. A pelvic examination will be done to determine the size and shape of the uterus. In women with fibroids, the uterus is often enlarged or irregularly shaped. An endometrial biopsy, in which a small sample of the uterine lining is removed, may be recommended in certain situations.
Laboratory tests may be recommended to look for bleeding disorders or thyroid disease. In some cases, the provider may recommend imaging tests, most commonly a pelvic ultrasound, to look for endometrial polyps, fibroids, or adenomyosis.
MEDICAL TREATMENT — The treatment of menorrhagia depends upon the cause and severity of the condition, the patient's preferences, the need to prevent pregnancy currently, and the woman's desire to have children in the future. Providers generally recommend that women with menorrhagia first try medical treatment (using medications). If one or more medical treatments are not successful, a surgical treatment may be recommended.
Combined oral contraceptives — Use of combined (estrogen and progesterone) oral contraceptives decreases menstrual blood loss over time. Alternatively, contraceptive patches or rings may be used instead of pills. All of these methods also help to prevent pregnancy. Combined oral contraceptives need to be taken daily.
Continuous dosing — Pills may be taken so that the woman has a period once per month or once every three to four months (called continuous dosing). This regimen is a particularly good treatment for women with painful periods. In this regimen, the woman takes the first three weeks of a pill pack, then immediately starts a new pack (without a break); the last week of (placebo) pills is not used. This can be continued for as long as desired.
Seasonale® is an extended cycle oral contraceptive product in which an active pill is taken every day for 12 weeks, followed by seven days of inactive (placebo) pills. Seasonique® is also an extended cycle oral contraceptive, although it contains seven days of a low dose estrogen pills instead of the placebo pills; this is intended to reduce breakthrough bleeding and estrogen withdrawal symptoms.
Taking an oral contraceptive for an extended time results in fewer periods per year, although many women experience breakthrough bleeding when starting this regimen. Breakthrough bleeding is inconvenient, but does not mean that there is an increased risk of pregnancy (unless pills are forgotten). (See "Patient information: Hormonal methods of birth control").
Progesterone — Progesterone is a hormone made by the ovary that is effective in preventing excessive bleeding in women with chronic anovulation. A synthetic form of progesterone, called progestin, can be given as a pill, injection, implant under the skin, or an intrauterine contraceptive. Progestin pills do not prevent pregnancy while the injection, implant, and intrauterine contraceptive do prevent pregnancy.
Pills — Progestin pills are usually taken for 11 to 14 days each month; within two weeks of the last pill, most women will begin to have a withdrawl bleed. Pills may be recommended every one to three months and help to prevent the uterine lining from becoming overly thickened, which can cause excessive bleeding. Progestin pills do not prevent pregnancy and are not useful for menorrhagia caused by adenomyosis, polyps, or fibroids.
Injection — Medroxyprogesterone acetate (Depo-Provera®) is a long-acting progestin that is injected deep into a muscle, such as the buttock or upper arm, once every three months. A similar preparation can be given subcutaneously (under the skin). Depo-Provera can reduce bleeding in women with menorrhagia, and it also is a very effective form of birth control; it prevents pregnancy for at least 12 weeks per dose. Because it is long-acting, it may not be ideal for women who wish to become pregnant shortly after stopping the medication. Although most women are able to conceive within 10 months, fertility may not return for up to 18 months after the last injection.
The most common side effects of Depo-Provera are irregular or prolonged bleeding and spotting, particularly during the first few months of use. Up to 50 percent of women completely stop having menstrual periods (amenorrhea) after one year of use. Menses generally return within six months of the last injection. Depo-Provera can cause weight gain and thinning of the bones in some women.
Intrauterine contraceptive — An intrauterine contraceptive (IUC) is a device that is made of molded plastic and coated with progestin (show picture 1). The IUC is inserted into a woman's uterus by a healthcare provider. A thin plastic string is attached to the device and can be felt inside the vagina. In the United States, the progestin-releasing IUC is called Mirena®. It is effective in reducing bleeding and preventing pregnancy for up to five years. The IUC is different than an intrauterine device (IUD), which is often coated with copper and causes heavier menstrual bleeding.
In one study, the Mirena reduced menstrual blood loss by as much as 97 percent after a year of use [1]. The most bothersome side effect was spotting during the first three months after the IUC was inserted; by six months, the majority of women had no bleeding or infrequent light bleeding. The progesterone releasing IUC is the most effective medical treatment for menorrhagia, is relatively inexpensive, and helps at least 60 percent of women to avoid surgical treatments for menorrhagia.
Implant — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. A healthcare provider inserts it under the skin in the upper inner arm (show picture 2). It prevents pregnancy and can control bleeding for up to three years. However, the implant can be removed sooner if pregnancy is desired. Insertion and removal can be done in an office or clinic. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
Nonsteroidal anti-inflammatory drugs (NSAIDs) — Nonsteroidal anti-inflammatory drugs, such as ibuprofen (Motrin® and Advil®) and mefenamic acid (Ponstel®), can help relieve the pain of menstrual cramping and reduce blood flow. NSAIDs are relatively inexpensive, have few side effects, and only need to be taken for three to five days during the menstrual period. However, some women find that NSAIDs cause stomach upset.
Gonadotropin-releasing hormone (GnRH) agonists — GnRH agonists may be used to temporarily control bleeding in women who are waiting to have a surgical treatment. Gonadotropin releasing hormone (GnRH) agonists (eg, nafarelin, leuprolide, goserelin) work by turning off ovarian production of estrogen, thereby causing a temporary type of menopause. The lack of estrogen causes the lining of the uterus to shrink and reduces pain in over 80 percent of patients. The drugs may be given as a nasal spray, implant, or injection.
The full dose of a GnRH agonist is usually taken for up to six months; they are not usually taken for longer due to the risk of bone thinning. Side effects of GnRH agonists include headaches in 20 percent of women, especially in patients with a history of migraine, and the signs and symptoms of menopause: lack of menstrual bleeding, hot flashes, vaginal dryness, decreased libido, insomnia, and loss of bone density (on average a 2 to 7 percent loss). Bone strength recovers substantially after the drug is stopped.
Many of these side effects can be minimized by giving estrogen or a bone strengthening drug along with the GnRH agonist. This treatment is not a permanent solution because heavy bleeding usually resumes when the drug is stopped.
Antifibrinolytic agents — Drugs like tranexamic acid and aminocaproic acid only need to be taken on the days of menses, do not interfere with fertility, and, since they act within two to three hours of administration, can also be used for acute control of bleeding. However, some women experience side effects, such as stomach problems, leg cramps, dizziness, and headaches, when they take these medications.
Danazol — Danazol is a medication that increases the level of androgens (male type hormone) and decreases the level of estrogen. This temporarily stops the menstrual period by inhibiting ovulation and ovarian production of estrogen and by shrinking the endometrium.
The medication is taken by mouth at a dose of 200 to 400 mg two to four times per day for 6 months or more. However, there is a high (75 percent) incidence of one or more side effects. Side effects may include weight gain, edema, decreased breast size, acne, oily skin, hirsutism (male pattern hair growth), deepening of the voice, headache, hot flashes, changes in libido, and mood changes. All of these changes are reversible, except for voice changes; however, a return to normal may take many months.
Danazol should not be taken by women with certain types of liver, kidney, and heart disease because these disorders may worsen. Women who could become pregnant must use a nonhormonal form of birth control (eg, condoms) while taking danazol because of a serious risk of birth defects if danazol is taken during pregnancy. (See "Patient information: Barrier methods of birth control").
SURGICAL TREATMENT — For women who have known abnormalities of the uterus that are known to cause menorrhagia, such as polyps or fibroids, surgical removal of these lesions often cures the menorrhagia. Some fibroids may also be treated by cutting off their blood supply. This procedure is called uterine artery embolization, and is discussed in depth in a separate topic review. (See "Patient information: Fibroids").
The two major surgical treatments for menorrhagia are:
Endometrial ablation — In this procedure, a physician destroys or removes most of the lining of the uterus. There are several methods of endometrial ablation, all of which use an instrument that is inserted through the cervix and into the uterine cavity. The procedure is usually done in a day surgery or office setting. To reduce pain, a sedative medication is given and local anesthesia is injected into the cervix. The most common postoperative side effects are cramping, vaginal discharge, and nausea. A pinkish vaginal discharge is present for two to three days after the procedure; this gradually becomes clear and watery discharge that lasts for two to 10 days. Uterine cramping may persist for 24 to 72 hours. Most women can resume their normal activities within a short time.
Endometrial ablation reduces and often eliminates menstrual blood flow in women with menorrhagia. However, it is not an option for women who may want to become pregnant in the future because the damage to the endometrium often prevents pregnancy.
A second endometrial ablation may be needed if symptoms persist or recur; between 5 and 20 percent of women who have this procedure have a second endometrial ablation to control uterine bleeding within three to five years of the initial procedure. In addition, 9 to 15 percent undergo a hysterectomy for persistent or new uterine symptoms.
Hysterectomy — Hysterectomy is surgical removal of the uterus. This is a permanent and complete treatment of menorrhagia since the source of bleeding (the uterus) is completely removed. However, hysterectomy is a major surgical procedure that has more complications and a longer recovery period than endometrial ablation. Pregnancy is not possible after hysterectomy. (See "Patient information: Abdominal hysterectomy" and see "Patient information: Vaginal hysterectomy").
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Women's Health Information Center
(www.4women.gov)
The Mayo Clinic
(www.mayoclinic.com)
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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Andersson, JK, Rybo, G. Levonorgestrel-releasing intrauterine device in the treatment of menorrhagia. Br J Obstet Gynaecol 1990; 97:690.
2. Warner, PE, Critchley, HO, Lumsden, MA, et al. Menorrhagia I: Measured blood loss, clinical features, and outcome in women with heavy periods: A survey with follow-up data. Am J Obstet Gynecol 2004; 190:1216.
3. Iyer, V, Farquhar, C, Jepson, R. Oral contraceptive pills for heavy menstrual bleeding. Cochrane Database Syst Rev 2000; :CD000154.
4. Lethaby, AE, Cooke, I, Rees, M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005; :CD002126.
5. Marjoribanks, J, Lethaby, A, Farquhar, C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev 2003; :CD003855.
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