Intended for healthcare professionals

Clinical Review Fortnightly review

Medical management of menorrhagia

BMJ 1999; 319 doi: (Published 20 November 1999) Cite this as: BMJ 1999;319:1343
  1. Andrew Prentice, consultant (
  1. Department of Obstetrics and Gynaecology, Box 223, Rosie Hospital, Cambridge CB2 2SW


    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

    • Age over 40

    • Persistent intermenstrual bleeding

    • Failed medical treatment

    • 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 norethisterone—arguably the least effective option—as first line treatment, whereas only 1 in 20 prescribe tranexamic acid—probably 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 …

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