BMJ 1999;319:1343-1345 ( 20 November )
Clinical review
Fortnightly review
Medical management of menorrhagia
Andrew Prentice, consultant.
Department of Obstetrics and
Gynaecology, Box 223, Rosie Hospital, Cambridge CB2 2SW
ap128{at}mole.bio.cam.ac.uk
 |
Introduction |
Excessive menstrual loss, or menorrhagia, is a significant
healthcare problem in the developed world (box 1). In the United Kingdom, 5% of women of reproductive age will seek help for this symptom annually1; by the end of reproductive life the
risk of hysterectomy (primarily for menstrual disorders) is
20%.2 This is also the situation in New
Zealand.3 Objectively, menorrhagia is defined as a
menstrual loss of 80 ml per month. Population studies have shown that
this amount of loss is present in 10% of the population4
yet nearly a third of all women consider their menstruation to be
excessive.5 This symptom thus creates a significant
workload for health services.
|
Box 1
: Indications for referral to a gynaecologist or for
surgical management
- Persistent intermenstrual bleeding
- Other factors
 for example, abnormal smear, associated severe
dysmenorrhoea
|
|
In clinical medicine the paradigm of evidence based medicine
currently holds sway. Evidence based medicine implies not only the
application of effective treatments but their rational use within a
rational overall management framework. In the management of excessive
menstrual loss there is good evidence that many doctors do not
necessarily prescribe the most effective treatments. In the United
Kingdom, for example, more than a third of general practitioners
prescribe norethisteronearguably the least effective optionas first
line treatment, whereas only 1 in 20 prescribe tranexamic
acidprobably the most effective first line treatment.6 The problem is not confined to primary care. In New Zealand, where the
use of tranexamic acid is restricted to secondary care, 50% of
gynaecologists still use luteal phase progestogens, and less than 10%
use tranexamic acid.7
|
Summary points
Menorrhagia is an important healthcare issue
Despite widely available evidence inappropriate treatments are being
prescribed
Guidelines exist for the appropriate management of menorrhagia
Appropriate treatments enhance patient choice and may increase patient
satisfaction
Medical treatments may provide an effective alternative to surgery
|
| |
Methods |
This review attempts to provide a rational overview of the
diagnostic and therapeutic management of menorrhagia, relying on the
systematic reviews presented in three paperstwo guidelines for the
management of excessive menstrual loss published in
1998
8 9
and a consensus view published in
199510and the Cochrane library for the source literature.
| |
Cause and pathology of menorrhagia |
Menorrhagia can be associated with both ovulatory and
anovulatory ovarian cycles. It is important to distinguish the
menstrual consequences of each cycle. Ovulatory ovarian cycles give
rise to regular menstrual cycles whereas anovulatory cycles result in
irregular menstruation or, extremely, amenorrhoea. This distinction is
critical in management. Both ovulatory and anovulatory cycles can give
rise to excessive menstrual loss in the absence of any other
abnormality; so called dysfunctional uterine bleeding. Other disorders
may be associated with excessive loss, for example, fibroids and
adenomyosis, but the association may not always be causal. Endocrine
disorders do not cause excessive menstrual loss, with the exception of
the endocrine consequences of anovulation. Equally, except in selected
populations, haemostatic disorders are rare causes of menorrhagia
despite suggestions to the contrary.11
Excessive menstrual loss in regular menstrual cycles is the most
common clinical presentation. Such patients ovulate regularly. Laboratory based research has shown that several abnormalities can
occur in the endometrium of women with this problemfor example, increased fibrinolytic activity12 and increased production
of prostaglandins.13 These observations provide the
rational basis for treatment in these women.
One consequence of excessive menstrual loss is iron deficiency anaemia.
In the western world menorrhagia is the commonest cause of iron
deficiency anaemia, and low haemoglobin concentrations may predict
objectively heavy menstrual loss.14
| |
Investigations |
Numerous investigations are undertaken for menorrhagia. The
purpose of investigation is threefold: (a) to assess the
morbidity associated with excessive menstrual loss, (b) to
exclude major intrauterine disease, and (c) to assess the
importance or otherwise of coexistent disorders. Box 2 details the
utility of commonly performed investigations.
|
Box 2
: Utility of commonly performed investigations for
menorrhagia
- Full blood count
- Haemoglobin concentration is a surrogate assessment for
excessive menstrual loss.14 Other indices within the full
blood count may more accurately assess iron state.9 Full
blood count should be undertaken in all women presenting with
menorrhagia
- Coagulation screen
- Tests for coagulopathies such as von Willebrand's disease
should only be undertaken when specifically indicated by the history
- Thyroid function tests
- There is little evidence to link hypothyroidism with excessive
menstrual loss15 and no evidence for hyperthyroidism to be
a cause.16 Thyroid function tests should not be routinely
undertaken
- Other endocrine investigations
- No significant endocrine abnormality has been detected in
menorrhagia.
17 18
There is no indication for any
endocrine investigation
- Pelvic ultrasound
- Routine pelvic ultrasound has little place in evaluating the
primary complaint of excessive menstrual loss.8 It is of
value in evaluating other pelvic disorders discovered during clinical
examination
- Endometrial sampling
- As part of initial assessment there is no place for endometrial
sampling (fig 1).9 Sampling should be combined with
further assessment of the endometrial cavity, for example,
hysteroscopy, in selected cases only. Selected cases would include
women over 40, women complaining of intermenstrual bleeding, and after
a failed trial of medical treatment
|
|
|
Box 3
: Factors influencing treatment choice
- Presence of ovulatory or anovulatory cycles
- Patient preference (particularly desire to avoid hormonal
therapy)
- Contraindications to treatment
|
|
| |
Choosing an appropriate treatment |
In most clinical cases no specific abnormality will have been
identified from the history, examination, and investigation; so called
dysfunctional uterine bleeding. The choice of treatment must therefore
be considered in relation to several factors (box 3). An element of
choice for the patient is important. It has been suggested that
involving patients in the decision making process may increase the
effectiveness of treatment.19 There is, however, a need to
properly inform patients to empower them to make informed choices.
Medical treatment can be conveniently divided into non-hormonal
and hormonal therapy. As there is no hormonal defect
17 18
the use of hormonal therapy does not correct an underlying disorder but
merely imposes an external control of the cycle. For many women, cycle
control is as important an issue as the degree of menorrhagia.
The two main first line treatments for menorrhagia associated with
ovulatory cycles are non-hormonal; the antifibrinolytic tranexamic acid
and non-steroidal anti-inflammatory drugs. The effectiveness of these
treatments has been shown in randomised trials20-22 and
reported in systematic reviews of treatment.
8 9 23 24
Tranexamic acid reduces menstrual loss by about a half and
non-steroidal anti-inflammatory drugs reduced it by about a third. Both
have the advantage of only being taken during menstruation itselfan
aid to complianceand are particularly useful in those women who
either do not require contraception or do not wish to use a hormonal
therapy (fig 2). They are also of value in treating excessive menstrual
blood loss associated with the use of non-hormonal intrauterine
contraceptive devices.
View larger version (28K):
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|
Fig 2.
Levonorgestrel releasing intrauterine system
may be an effective alternative to surgery and useful in patients
requiring contraception
|
|
Traditionally, hormonal therapy for menorrhagia has been progestogens
given during the luteal phase of the cycle. Such treatments are
ineffective.25 Despite this they remain the first choice of many general practitioners and gynaecologists.
6 7
Progestogens are effective when given for 21 days in each
cycle,
25 26
but the side effects may be such that
patients would not choose to continue with treatment.26
Although progestogens have a contraceptive effect their use in this way
may not be the best choice where contraception is required by the patient.
The combined contraceptive pill is both an effective contraceptive and
treatment for menorrhagia when compared with other medical
treatment.27 It is not, however, possible to expand upon
this statement as there is a lack of good quality data,27 and the use of the contraceptive pill in this area has been
insufficiently studied. Nevertheless, like cyclical progestogens,
combined oral contraceptives are useful for anovulatory bleeding as
they impose a cycle. More fully evaluated is the recently licensed
levonorgestrel releasing intrauterine system. This system (fig 3)
consists of a T shaped intrauterine device sheathed with a reservoir of
levonorgestrel that is released at the rate of 20 µg daily. This low
level of hormone minimises the systemic progestogenic side effects and patients are more likely to continue with this therapy than cyclical progestogen therapy.26 The levonorgestrel releasing
intrauterine system, marketed as Mirena in the United Kingdom, is not
yet licensed for use in the treatment of menorrhagia but when
contraception is also required its use is legitimate. It exerts its
clinical effect by preventing endometrial proliferation and
consequently reduces both the duration of bleeding and the amount of
menstrual loss.27 For up to 6 months patients may
experience irregular bleeding or spotting, especially in the first 3 months, but by 12 months most women have only light bleeding, and a
major proportion are amenorrhoeic.9 Many of the potential
problems of bleeding and spotting can be overcome by thorough
pretreatment counselling.
|
Box 4
: Effective treatments for menorrhagia
- Non-steroidal anti-inflammatory drugs
- Combined oral contraceptives
- Cyclical (21 days) progestogens
- The levonorgestrel releasing intrauterine system (Mirena)
|
|
The levonorgestrel releasing intrauterine system is advocated as
an alternative to surgery. Two studies have examined the effect of
offering this treatment to women on waiting lists for hysterectomy.
28 29
In the first of these studies 50 women
on a waiting list were offered this treatment, and 82% (41/50) were removed from the waiting list as a result.28 Lahteenmaki
et al29 randomised women on surgical waiting lists to
continue with their current regimen or to use a levonorgestrel
releasing intrauterine system; 64% of women using the system cancelled
their surgery compared with 14% of women not using the
system.27 When compared with minimally invasive techniques
it seems to be equally effective.30 Whether this treatment
will provide a long term alternative to surgery remains to be evaluated.
Excessive menstrual loss is a major healthcare problem. The publication
of guidelines
8 9
acknowledges that inappropriate management is being applied. Effective medical treatments exist (box 4)
and have a rational basis for their use. Increased use of effective
treatments will improve patient choice and provide an alternative to surgery.
| |
Acknowledgments |
Competing interests: None declared.
| |
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