Menorrhagia
Menorrhagia: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Albert A. Meyer
Approach
Menorrhagia, defined as excessive bleeding from the uterus, is a common gynecologic complaint. Each year, 200,000 American women undergo hysterectomy for the treatment of menorrhagia. Approximately 20% of women consult their doctor during their lives about this problem. Of women, 15% will have at least one endometrial sampling and 10% of all American women will have had a hysterectomy by age 50 years. Although it is caused by anovulatory cycles in most cases, menorrhagia can be related to pregnancy, infection, cancer, and thyroid disease. When unrelated to any uterine or systemic disease, it is referred to as dysfunctional uterine bleeding (1).
History (2)
A. A menstrual and reproductive history is necessary. First, assess the first day of the last menstrual period and the first day of the previous menstrual period; the regularity, duration, frequency, and intermenstrual flow; and the number of pads or tampons per period.
B. Pregnancy should always be considered and diagnosed, if present. Complications of pregnancy (e.g., spontaneous abortion, ectopic pregnancy, abruptio placentae, and placenta previa) need to be considered if pregnancy is diagnosed.
C. Weight loss or gain, excessive exercise, anxiety or stress disorders, as well as symptoms of systemic disease (e.g., coagulopathy; thyroid, renal, and hepatic disease), must be considered when taking the history.
D. A key question. Is the patient having ovulatory or anovulatory cycles? Do molimenal symptoms (e.g., edema, abdominal bloating, pelvic cramping, and breast fullness) precede menses that follow an ovulatory cycle. If these symptoms are not present and the patient has irregular, heavy periods, the patient is anovulatory and has dysfunctional uterine bleeding.
E. How old is the patient?
1. Menarche to 16 years. Without molimenal symptoms and with irregularity, the problem in the young woman is most probably anovulatory. Whereas some irregularity is normal, it is not normal to soak 25 to
30 tampons or pads per day. In this setting, pregnancy remains a consideration if the patient is sexually active. Fever and pelvic pain can indicate pelvic inflammatory disease (PID). Easy bruising suggests a coagulopathy and neurologic symptoms (e.g., blurred vision, visual field defects, and headache) point to a pituitary lesion.
2. Age 16 to 40 years. Anovulation is a less common cause of abnormal bleeding; up to 8% of problems are caused by pregnancy and contraception complications in this age group. Endometriosis, endometrial hyperplasia, and endometrial polyps increase in frequency as a woman ages. PID and endocrinopathies also occur in this age group.
3. Age 40 years and above. Abnormal bleeding in this age group should arouse suspicion of cancer, until proved otherwise. Of women in this age group, 90% who have abnormal bleeding are anovulatory. Menopausal symptoms, use of estrogens, and personal or family history of malignancy are important to elicit.
Physical examination
A. Assess vital signs and the patient’s general appearance. Signs of impending shock (e.g., hypotension and tachycardia) are likely related to pregnancy, particularly in the younger age group, but they can be related to trauma, sepsis, or cancer.
B. Pallor not associated with hypovolemia can be found with chronic blood loss associated with anovulatory cycles, leiomyoma, blood dyscrasia, or malignancy (Chapter 16.1).
C. Fever, leukocytosis, and pelvic tenderness are usually found in acute PID (Chapter 2.6).
D. Pelvic masses found on physical examination point toward abscess, ectopic pregnancy, or malignancy.
E. Signs of thyroid disease (e.g., rapid or slow pulse, reflex changes, hair changes, and thyromegaly) can be associated with menstrual abnormalities.
F. Excessive bruising can indicate nutritional deficiency, eating disorder, trauma, abuse, medication overuse, or coagulopathy (Chapter 15.3).
Testing
A. A baseline complete blood count and serum pregnancy test are essential in most pre- and perimenopausal women.
B. A bleeding disorder should be excluded with a platelet count, a prothrombin time, a partial thromboplastin time, and a bleeding time.
C. Screening for sexually transmitted diseases and thyroid dysfunction, particularly in those of childbearing age, is important.
D. Any nonpregnant woman with irregular bleeding and a pelvic mass requires evaluation with ultrasound, computed tomography (CT), or laparoscopy.
E. Endometrial sampling is recommended before initiating hormone therapy in women aged more than 30 years or in those older than 20 years with prolonged bleeding. Long-term estrogen stimulation in anovulatory patients can result in endometrial hyperplasia, which can result in endometrial carcinoma. This procedure is best done on the first day of menses to avoid an unexpected pregnancy. In the perimenopausal or postmenopausal woman, amenorrhea preceding abnormal bleeding suggests endometrial carcinoma. It is useful to obtain a transvaginal ultrasound prior to the endometrial biopsy because biopsy is often unnecessary if the endometrial stripe is less than 5 mm thick.
Diagnostic assessment (3)
Menorrhagia is defined as excessive menstrual flow. The definition of excessive varies widely among patients but “different” and “worrisome” to the patient appear to be important historical features. When excessive bleeding is regular, pregnancy and systemic illness must be excluded. Of menorrhagia, 90% of cases have no obvious cause and it is thought to be anovulatory or dysfunctional. Dysfunctional bleeding is usually not preceded by premenstrual (molimenal) symptoms. It is seen most frequently at the extremes of the reproductive years, after menarche and before the onset of menopause. Pregnancy must always be excluded as a cause in women of childbearing age. Excessive estrogen stimulation that occurs during anovulatory cycles can lead to endometrial hyperplasia and to carcinoma. Endometrial biopsy is indicated for most nonpregnant women with prolonged, irregular bleeding. Abnormal bleeding following amenorrhea in menopause is endometrial carcinoma until proved otherwise. Any pelvic mass occurring in the context of menorrhagia ought to be evaluated with ultrasound, CT, or magnetic resonance imaging. If confusion still exists, laparoscopy or hysteroscopy with saline infusion may be indicated.
References
1. Rosenfield J. Treatment of menorrhagia due to dysfunctional uterine bleeding. Am Fam Physician 1996;53:165–172.
2. Smith CB. Pinpointing the cause of abnormal uterine bleeding. Women’s Health in Primary Care 1998;1(10):835–844.
3. Nelson AL. A practical approach to dysfunctional uterine bleeding. Fam Prac Recertification 1997;19(8):14–39.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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