Menorrhagia may be defined as a heavy menstrual bleeding over several cycle. The traditional, objective, definition of menorrhagia is of menstrual blood loss of 80 ml or more per cycle.
Measured blood loss has been shown to have little correlation with women’s own perceptions of bleeding heaviness and so the clinical definition typically used is that of excessively heavy bleeding for an individual.
In practice, any blood loss that is perceived by a women to be excessive or as having a negative impact on her quality of life warrants counseling and possibly treatment.
A significant population of women complaining of Menorrhagia will have a measured blood loss less than 80 ml per cycle. Menorrhagia is a major reason for gynecological referral.
Various methods have been developed for the objective assessment of menstrual loss. These have not been very helpful in the clinical management of Menorrhagia.
Menorrhagia may start anytime from menarche through the reproductive years to menopause and in the postmenopausal women on hormone replacement therapy. It can start suddenly or run a chronic course.
During the normal menstrual cycle, proliferation of endometrium is induced by the effect of oestrogens, while progestogens induce secretory differentiation. For menstruation to occur there is extensive arteriolar vasoconstriction and bleeding occurs as vessels dilate.
The causes of Menorrhagia can vary from a dysfunctional aetiology to the existence of pelvic pathology and rarely to systemic disorders.
Apart from the social and psychological effects of Menorrhagia, the severity can be assessed by estimation of the hemoglobin level and other blood indices and the effect on the iron status. Menorrhagia is the commonest cause of iron deficiency anaemia in the reproductive age women.
Cause of Menorrhagia
The causes of Menorrhagia can be categorized into three main groups, namely:
- Dysfunction uterine bleeding (DUB),
- Bleeding due to pelvic pathology,
- Medial disorders including coagulation defects.
DUB is a diagnosis of exclusion.
General causes
Systemic disease occasionally causes Menorrhagia. Systemic causes of Menorrhagia can vary from
- Blood dyscresia, leukemia
- Coagulopathy, thrombocytopenic Purpura, severe anemia
- Thyroid dysfunctions, both hypothyroidism and hyperthyroidism
- Early stage of genial tuberculosis
- Von Willebrand’s disease and other blood factor deficiency states
- Autoimmune disorders like idiopathic thrombocytopenia and systemic lupus erythomatosus;
- Use of anticoagulants like warfarin
- Chronic liver disease
Pelvic pathology
- Uterine fibroids
- Adenomyosis
- Endometrial polyps
- Endometriosis
- Endometritis;
- Presence of intra-uterine contraceptive device (IUCD)
- Endometrial hyperplasia;
- Rarely, endometrial cancer.
Contraceptive uses
- IUCD
- Poststerlisation menorrhagia
- Progestogen – only pills
Hormonal or dysfunctional
Ovulatory
- Irregular shedding of endometrium, irregular ripening of endometrium
Anovulatory
- Anovulatory cycles (oestrogen withdrawl)
- Metropathia haemorrhagica
Large submucous fibroids and pedunculated fibroid polyps are associated with the heaviest degree of loss.
Unsuspected pregnancy bleeding can present like an acute episode of Menorrhagia or complicate an ongoing chronic Menorrhagia. Menorrhagia can occur in postmenopausal women taking hormone replacement therapy.
Symptoms of Menorrhagia
The word Menorrhagia means excessive flow of blood during the menstruation. In this condition the menstrual period may be regular as to time, or it may come too early, or it may last too long.
Excessive flow of blood produces paleness of face, sunken eyes, and is usually attended with lassitude, a sense of oppression in the head, wandering pains in the lack, loins, and lower extremities: sense of weight and pressure in the pelvis; chilliness, cold feet, weak sight, weak pulse and impaired appetite.
