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Menorrhagia

Background: Menorrhagia is menstruation at regular cycle intervals but with excessive flow and duration. It is defined clinically as total blood loss exceeding 80 mL per cycle or menses lasting longer than 7 days. Menorrhagia is one of the most common gynecologic complaints in contemporary gynecology. Current gynecological surveys report that 30% of all premenopausal women perceive their menses to be excessive. The World Health Organization recently reported that 18 million women aged 30-55 years perceive their menstrual bleeding to be exorbitant. Reports show that only 10% of these women experience blood loss severe enough to be defined clinically as menorrhagia. A normal menstrual cycle is 21-35 days in duration, bleeding lasting an average of 7 days, and flow between 25 and 80 mL. Menorrhagia must be distinguished clinically from other common gynecologic diagnoses. These include metrorrhagia (flow at irregular intervals), menometrorrhagia (frequent, excessive flow), polymenorrhea (bleeding at intervals <21 d), and dysfunctional uterine bleeding (abnormal uterine bleeding without any obvious structural or systemic abnormality). Nearly 30% of all hysterectomies performed in the United States are performed to alleviate heavy menstrual bleeding. Definitive surgical correction has been the mainstay of treatment for menorrhagia. Modern gynecology dictates the trend toward conservative therapy for cost containment and because many women desire to preserve their uteruses. Alternatives to hysterectomy also are the result of statistics revealing that nearly 50% of uterine pathology findings from hysterectomies for menorrhagia are free of disease and histopathologic abnormalities. Heavy menstrual bleeding is a subjective finding, making the exact problem definition difficult. Treatment regimens must address the specific facet of the menstrual cycle the patient perceives to be abnormal, (ie, cycle length, quantity of bleeding). Finally, treatment success usually is evaluated subjectively by each patient, making positive outcome measurement difficult.   Pathophysiology: Knowledge of normal menstrual function is imperative in understanding the etiologies of menorrhagia. Four phases constitute the menstrual cycle, follicular, luteal, implantation, and menstrual. In response to gonadotropin-releasing hormone (GnRH) from the hypothalamus, the pituitary gland synthesizes follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which induce the ovaries to produce estrogen and progesterone.

During the follicular phase, estrogen stimulation results in an increase in endometrial thickness. This also is known as the proliferative phase. The luteal phase is intricately involved in the process of ovulation. During this phase, also known as the secretory phase, progesterone causes endometrial maturation. If fertilization occurs, the implantation phase is maintained. Without fertilization, estrogen and progesterone withdrawal results in menstruation. Etiologic causes are numerous and often unknown. Factors contributing to menorrhagia can be sorted into several categories, including organic, endocrinologic, anatomic, and iatrogenic. If the bleeding workup does not provide any clues to the etiology of the menorrhagia, a patient often is given the diagnosis of dysfunctional uterine bleeding (DUB). Most cases of DUB are secondary to anovulation. Without ovulation, the corpus luteum fails to form, resulting in no progesterone secretion. Unopposed estrogen allows the endometrium to proliferate and thicken. The endometrium finally outgrows its blood supply and degenerates. The end result is asynchronous breakdown of the endometrial lining at different levels. This also is why anovulatory bleeding is heavier than normal menstrual flow. Hemostasis of the endometrium is directly related to the functions of platelets and fibrin. Deficiencies in either of these components results in menorrhagia for patients with von Willebrand disease or thrombocytopenia. Thrombi are seen in the functional layers but are limited to the shedding surface of the tissue. These thrombi are known as "plugs" because blood can only partially flow past them. Fibrinolysis limits the fibrin deposits in the unshed layer. Following thrombin plug formation, vasoconstriction occurs and contributes to hemostasis. Anatomic defects or growths within the uterus can alter either of the aforementioned pathways (endocrinologic/hemostatic), causing significant uterine bleeding. The clinical presentation is dependent on the location and size of the gynecologic lesion. Organic diseases also contribute to menorrhagia in the female patient. For example, in patients with renal failure, gonadal resistance to hormones and hypothalamic-pituitary axis disturbances result in menstrual irregularities. Most women in this renal state are amenorrheic, but others also develop menorrhagia. If uremic coagulopathy ensues, it usually is due to platelet dysfunction and abnormal factor VIII function. The resulting prolonged bleeding time causes menorrhagia that can be very tenuous to treat. Due to the overwhelming factors that can contribute to the dysfunction of either the endocrine or hematological pathways, in-depth knowledge of an existing organic disease is just as imperative as understanding the menstrual cycle itself.

Age: • Any woman of reproductive age who is menstruating may develop menorrhagia. Mortality/Morbidity: Infrequent episodes of menorrhagia usually do not carry severe risks to women general health. are at risk for serious medical sequelae. taking a detailed patient history is imperative. This is because the most common cause of heavy menses in the younger population is anovulatory cycles. . dry skin. Other sequelae associated with menorrhagia usually are related to the etiology. fatigue. Menorrhagia is the most common cause of anemia in premenopausal women. Inquiries should include the following: • Exclusion of pregnancy o This is the most common cause of irregular bleeding in women of reproductive age. Patients who do not respond to medical therapy may require surgical intervention to control the menorrhagia. • Patients who lose more than 80 mL of blood. This level of anemia necessitates hospitalization for intravenous fluids and possible transfusion and/or intravenous estrogen therapy. especially repetitively. These women are likely to develop iron-deficiency anemia as a result of their blood loss. This usually can be remedied by simple ingestion of ferrous sulfate to replace iron stores. and other related symptoms. cold intolerance. Considering the lengthy list of possible etiologies that contribute to menorrhagia.Frequency:   • In the US: While menorrhagia remains a leading reason for gynecologic office visits. only 10-20% of all menstruating women experience blood loss severe enough to be defined clinically as menorrhagia. If the bleeding is severe enough to cause volume depletion. in which bleeding does not occur at regular intervals. weight gain) in addition to the effects of significant blood loss. For example. palpitations. Most patients with menorrhagia are older than 30 years. History: Symptoms related by a patient with menorrhagia often can be more revealing than laboratory tests. • Sex: • Only females are affected by menorrhagia. hair loss. patients may experience symptoms associated with a lowfunctioning thyroid (eg. patients may experience shortness of breath. with hypothyroidism.

Records from other physicians or hospitalizations may prevent redundancy in ordering lab work or diagnostic imaging. o • Age o Young patients. Asking the patient what type of pad (liner vs overnight) was used and if it was soaked may add some insight into what the patient believes to be heavy bleeding. a bleeding disorder must be considered. Endometrial hyperplasia must be considered in women who are obese. Best estimates usually are the only source clinicians have available to consider. Postmenopausal women with any uterine bleeding should receive an immediate workup for endometrial cancer. fibroids) is helpful. If bleeding does not respond to usual therapy in this age group.  o Pregnancy should be the first diagnosis to be excluded before further testing or medications are instituted. Organic causes can be anything from thyroid dysfunction to renal failure. from menarche to the late-teen years. aged 70 or older. Women aged 30-50 years may have organic or structural abnormalities. or have diabetes. nulliparous. o . the most common etiology of her bleeding is anovulation. Fibroids or polyps are frequent anatomical findings. Anovulatory bleeding is most common in young girls (aged 12-18 y) and common in obese females of any reproductive age. most commonly have anovulatory bleeding due to the immaturity of their hypothalamic-pituitary axis. Helpful references for totaling blood loss may include that the average tampon holds 5 mL and the average pad holds 5-15 mL of blood. Quality of bleeding involves the presence of clots and their size. o • Menses pattern from menarche o If a young patient has had irregular menses since menarche. • Quantity and quality of bleeding o Quantity is a very subjective issue when considering vaginal bleeding. o o o • Pelvic pain and pathology o Knowing if a patient has any long-standing diagnosis or known pathology (eg.

If either the hypothalamic-pituitary axis or the coagulation paths are disrupted.o If a patient's bleeding normally occurs at regular intervals and the irregularity is new in onset. • Sexual activity o Simple vaginitis (eg. o • Symptoms of thyroid dysfunction: The alteration of the hypothalamic-pituitary axis may create either amenorrhea (hyperthyroidism) or menorrhagia (hypothyroidism). while gonorrhea and chlamydia may present with heavier bleeding attributed primarily to the copious discharge mixed with the blood. If a patient has recently discontinued birth control pills. o • Galactorrhea (pituitary tumor): Any patient complaining of a milky discharge from either breast (while not pregnant. o o • Contraceptive use (intrauterine device or hormones) o Commonly. Excessive bruising or known bleeding disorders • . Systemic illnesses (hepatic/renal failure or diabetes) o • As explained in the Introduction. heavy bleeding may result. When they do have a period. regardless of age. The etiology of this is explained in the Introduction to this article. leading to vaginal bleeding in the weeks following a delivery. endometritis) also may be due to organisms unrelated to sexual activity. pathology must be ruled out. it may be very heavy and cause concern for the patient. This actually is normal because most oral birth control pills decrease the flow and duration of a woman's menses. Chlamydia is a common cause of postpartum endometritis. organic diseases may affect either the hormonal or hematologic pathways that are involved in the manifestation of menorrhagia. an intrauterine device (IUD) causes increased uterine cramping and menstrual flow. postpartum. she may return to her "natural" menses and report an increase in flow. or breastfeeding) needs a prolactin level to rule out a pituitary tumor. candidal. bacterial vaginosis) may cause intermenstrual bleeding. A postpartum infection (eg. o • Presence of hirsutism (polycystic ovarian syndrome) o These patients commonly are obese and in an anovulatory state.

This bleeding often is heavy and worrisome to patients if they are not forewarned. anemia): This may help confirm the patient's history of very heavy bleeding and/or prompt immediate inpatient care. leading to anovulatory bleeding (see Presence of hirsutism). • Initial inspection should include evaluation for the following: o Signs of severe volume depletion (eg. Adipose tissue is a locale for estrogen conversion. Physical: The physical examination should be tailored to the differential diagnoses formulated by the results of the patient's history. Ecchymosis: This usually is a sign of trauma or a bleeding disorder. A patient treated with any progestin therapy may have a withdrawal bleed after cessation of the medication. Obesity: This is an independent risk factor for endometrial cancer. o • Current medications (hormones or anticoagulants) o o Any medication that prolongs bleeding time may cause menorrhagia. This is a very common presentation for an undiagnosed bleeding disorder (von Willebrand disease) in a young girl. the larger the patient. Pronounced acne: This is a sign of PCOS. Therefore.o This is especially important in a young patient who does not stop bleeding during her first menses. hirsutism): This usually points to polycystic ovarian syndrome (PCOS). the more increased the risk (and the higher the unopposed estrogen level on the endometrium). • Previous medical or surgical procedures/diagnoses: This also is helpful in preventing duplication of testing. Purpura: This also is a sign of trauma or a possible bleeding disorder. o o o o o • General examination should include evaluation of the following: o o o Visual fields Bleeding gums Thyroid evaluation . Signs of androgen excess (eg.

o o Causes: Etiologies of menorrhagia are divided into 4 categories. Cervical motion tenderness: This is a common symptom of pelvic inflammatory disease (PID) that usually is caused by gonorrhea or chlamydia. especially in young nulliparous women. and thromboasthenia. VII. Ovarian cancer may present with intermenstrual bleeding as its only symptom. and iatrogenic. • Organic causes of menorrhagia include infection. because it can lead to pelvic adhesions and infertility. organic. and confirm the actual site of the bleeding (if present). factor II. An enlarged uniformly shaped uterus in a postmenopausal patient with bleeding suggests endometrial cancer until proven otherwise. o Infections can be of any genitourinary origin. Rare but deadly ovarian tumors also can present in teenage girls. V. and IX deficiencies. This is an important diagnosis to exclude. Either of these problems may lead to heavy uterine bleeding. Assess as follows: o Uterine size. Organ dysfunction causing menorrhagia includes hepatic or renal failure. The aforementioned sexually transmitted diseases are of greater concern in the teenage and early adult population. and organ dysfunction. prothrombin deficiency. especially in the postmenopausal woman who has negative findings after a workup for vaginal bleeding. Any suspicion of an adnexal mass should prompt an immediate pelvic ultrasound. These include von Willebrand disease. o o . anatomic. endocrinologic.o o • • Galactorrhea Enlarged liver or spleen Pelvic examination should evaluate for the presence of external genital lesions. Bleeding from the urethra or rectum always must be considered in the workup. Adnexal tenderness or masses: This is especially concerning in patients older than 40 years. Coagulation disorders can evade diagnosis until menarche. and contour: An enlarged irregularly shaped uterus suggests fibroids if the patient is aged 30-50 years. bleeding disorders. Chronic liver disease impairs production of clotting factors and reduces hormone metabolism (eg. estrogen). when heavy menstrual bleeding presents as an unrelenting disorder. Vaginal/cervical discharge: Look for a copious discharge indicating infection. idiopathic thrombocytopenia purpura (ITP). shape.

The hallmarks of PCOS are anovulation. pituitary tumors. This is most common in adolescent and perimenopausal populations. The blood supply to the fibroid or polyp is different compared to the surrounding endometrium and is thought to function independently. This blood supply is greater than the endometrial supply and may have impeded venous return. endometrial hyperplasia. Insulin resistance is common and increases androgen production by the ovaries. anovulatory cycles. PCOS. This overproduction of insulin leads to ovarian production of androgens. This also is why intramural fibroids may cause a significant amount of pain and cramping. This leads to decreased LH and FSH levels.• Endocrine causes of menorrhagia include thyroid and adrenal gland dysfunction. thereby preventing normal uterine attempts at hemostasis. The finding of menorrhagia at irregular intervals without any known organic etiology confirms the clinical diagnosis. Even subclinical cases of hypothyroidism produce heavy uterine bleeding in 20% of patients. irregular menses. The mechanism by which endometrial polyps or fibroids cause menorrhagia is not well understood. but fibroids may occur almost anywhere on the uterus. and vasculature imbalance. Vasculature imbalance is theorized to be the result of a discrepancy between the vasoconstricting and aggregating actions of prostaglandin F2 (alpha) and thromboxane A2 and the vasodilating actions of prostaglandin E2 and prostacyclin on the myometrial and endometrial vasculature. as occurs in PCOS. Interim stages of menorrhagia result until hypogonadism manifests. and pregnancy. endometrial polyps. Prolactin-producing pituitary tumors cause menorrhagia by disrupting (GnRH) secretion. The most common etiology of heavy uterine bleeding is anovulatory cycles. which ultimately cause hypogonadism. obesity. o Fibroids and polyps are benign structures that distort the uterine wall and/or endometrium. Fibroids located within the uterine wall may inhibit muscle contracture. Hyperinsulinemia is a direct consequence of obesity. causing pooling in the areas of the fibroid. Heavy pooling is thought to weaken the endometrium in that area. and break-through bleeding ensues. o o o o o • Anatomic etiologies for menorrhagia include uterine fibroids. o Both hypothyroidism and hyperthyroidism result in menorrhagia. Fibroids may o o . Menorrhagia usually resolves with correction of the thyroid disorder. Either may be located within the uterine lining. and hirsutism. obesity.

Endometrial hyperplasia can lead to endometrial cancer in 1-2% of patients with anovulatory bleeding. including menses. Coagulation factors: These studies are used to rule out von Willebrand disease. This type of menorrhagia also is easily reversible o o Lab studies: • Complete blood count o The CBC count may be used as a baseline for hemoglobin and hematocrit or to rule out anemia. or ectopic pregnancy. Steroid hormones and chemotherapy agents disrupt the normal menstrual cycle. If a woman takes unopposed estrogen (without progesterone). o • Iron studies: Total iron-binding capacity (TIBC) and total iron are used to assess iron stores. o IUDs can cause increased menstrual bleeding and cramping due to local irritation effects.enlarge to the point that they outgrow their blood supply and undergo necrosis.3 compared to nonusers and 9. • • • . incomplete abortion. All of these conditions cause ovarian dysfunction leading to possible menorrhagia. Bleeding usually denotes threatened abortion. and medications (eg. Human chorionic gonadotropin: Pregnancy remains the most common cause of abnormal uterine bleeding in patients of reproductive age. steroid hormones. regardless of the etiology. or IX deficiency. V. Use the platelet count in conjunction with a peripheral smear if a coagulation defect is suspected. anticoagulants). VII. and factor II. Thyroid function tests and prolactin level: These tests can rule out hyperthyroidism or hypothyroidism and hyperprolactinemia. but it is a diagnosis of exclusion in postmenopausal bleeding (average age at menopause is 51 y). ITP. • Iatrogenic causes of menorrhagia include IUDs. This also causes a great deal of pain for patients. These tests should be ordered sparingly because they are expensive tests for rare disorders. Anticoagulants decrease clotting factors needed to cease any normal blood flow. o Endometrial hyperplasia usually results from unopposed estrogen production. chemotherapy agents.5 if taken for 10 years or longer. her relative risk of endometrial cancer is 2. which is restored easily upon cessation of the products.

fibroids). The findings yielded from pelvic examinations may be limited if patients are obese. and androgen levels help diagnose patients with suspected PCOS. superior methods of assessment must be used in high-risk patients. Tests: Papanicolaou (Pap) smear test results for cervical cytology should be current. In . cortisol. and contour. BUN and creatinine tests assess renal function. such as in persons with alcoholism or hepatitis. FSH. Sonohysterography (saline-infusion sonography): Fluid infused into the endometrial cavity enhances intrauterine evaluation. or eccentrically located endometrial lesions may be missed by an in-office endometrial biopsy (EMB). One advantage is the ability to differentiate polyps from submucous leiomyomas (ie. o o • Hormone assays o o LH. and adnexal areas. Studies: Imaging   • Small. • • Other   • • Procedures:   • Because routine EMB and conventional imaging studies may miss small or laterally displaced lesions. irregular. endometrium. and/or adnexa.• Liver function and/or renal function tests o Order liver function tests (LFTs) when liver disease is suspected. Adrenal function tests (eg. Cervical specimens should be obtained if the patient is at risk for an infection. Pelvic ultrasound is the best noninvasive imaging study to assess uterine shape. size. 17-alpha hydroxyprogesterone [17-OHP]) delineate hyperandrogenism in women with suspected adrenal tumors. Congenital adrenal hyperplasia (CAH) is diagnosed primarily by testing 17-OHP. These limitations can lead to further imaging studies to inspect the uterus. focal. endometrial thickness. Dysfunction of either organ can alter coagulation factors and/or the metabolism of hormones.

obesity. If no tissue is returned after an EMB is performed. High-risk patients who should be biopsied include those with hypertension.   o The histologic diagnosis is missed in less than 2% of patients who undergo hysteroscopy with directed biopsy. Endometrial hyperplasia with atypia (especially atypical adenomatous hyperplasia) generally is considered equivalent to an intraepithelial malignancy. o This technique is used to directly visualize the endometrial cavity by close contact. .   o A biopsy sample should be taken. PCOS). or hyperplasia. atypical glandular cells (AGUS) on Pap smear. o o Histologic Findings: Understanding EMB results is essential for any physician treating menorrhagia. performing an in-office biopsy or imaging studies may be limited by patient problems such as obesity or cervical stenosis. Endometrial hyperplasia (except atypical adenomatous) requires progesterone on timed 12-day regimens outlined in the Treatment. diabetes. most likely the endometrium is atrophic and requires estrogen. and hysterectomy usually is advised. regardless of the endometrial appearance. chronic anovulation (eg. Simple proliferative endometrium is normal and does not require treatment. EMB findings are used to assess the stage and proliferation of the endometrial stroma and glands. • Hysteroscopy: This can be done in the office but may require anesthesia if the patient has a low pain tolerance or adequate visualization is not obtainable. • Endometrial biopsy o This procedure is used in women who are at risk for endometrial carcinoma. polyps. Both tests are accepted as equal in value and are approximately 98% accurate. Many studies have been done to compare the results of EMB and dilatation and curettage (D&C). and those older than 70 years or any woman older than 35 years with new-onset irregular bleeding (especially if nulliparous). new-onset menorrhagia.addition.

• Nonsteroidal anti-inflammatory drugs   o Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line medical therapy in ovulatory menorrhagia. Therapy with progestin results in a 15% reduction in menstrual blood flow when used alone. nausea. preventing ovulation. o o o . NSAIDs are ingested for only 5 days of the entire cycle. family history. and depression. Medication cost and adverse effects also are factored in because they may play a direct role in patient compliance. Menstrual blood loss is reduced as much as 60% due to endometrial atrophy. OCPs suppress pituitary gonadotropin release. and desire for fertility. coexisting medical diseases. possibly. thereby maintaining the endometrium in a state of down-regulation. Common adverse effects include weight gain. o o o • Progestin therapy o o Progestin is the most frequently prescribed medicine for menorrhagia. the reduction in blood loss is as high as 86%. related weight gain in some individuals. and. breakthrough bleeding. Factors taken into consideration when selecting the appropriate medical treatment include the patient age. Medical Care: Medical therapy must be tailored to the individual. NSAIDs reduce prostaglandin levels by inhibiting cyclooxygenase and increasing the ratio of prostacyclin to thromboxane.Any biopsy that reveals endometrial carcinoma should prompt immediate referral to a gynecologic oncologist for treatment outlined by current oncology protocols associated with the grade and stage of the cancer. Progestin works as an antiestrogen by minimizing the effects of estrogen on target cells. o • Oral contraceptive pills o Oral contraceptive pills (OCPs) are a popular first-line therapy for women who desire contraception. edema. limiting their most common adverse effect of stomach upset. Common adverse effects include breast tenderness. If administered to a patient with an IUD. headaches. o o Studies show an average reduction of 25-35% in menstrual blood flow.

o o Surgical Care: Surgical management has been the standard of treatment in menorrhagia due to organic causes (eg.• Gonadotropin-releasing hormone agonists o These agents are used on a short-term basis due to high costs and severe adverse effects. resulting in hypogonadism. follow up with estrogen-progestin therapy for 7 days. They inhibit pituitary release of FSH and LH. fibroids) or when medical therapy fails to alleviate symptoms. and. o This procedure is used best in conjunction with hysteroscopy to evaluate the endometrial cavity for pathology. estrogens o • Conjugated   o These agents are given intravenously every 4 hours in patients with acute bleeding. typically 1-2 months. It is not used for treatment because it provides only short-term relief. decreasing breast size. This is followed by OCPs for 3 months. lower voice. A prolonged hypoestrogenic state leads to bone demineralization and reduction of high-density lipoprotein (HDL) cholesterol. • Dilatation and curettage o A D&C should be used for diagnostic purposes. It is contraindicated in patients with known or suspected pelvic infection. If menses slows. Surgical treatment ranges from a simple D&C to a full hysterectomy. infection. o o o • Danazol   o Danazol competes with androgen and progesterone at the receptor level. o • Transcervical resection of the endometrium . A D&C procedure may be necessary if no response is noted in 24 hours. rarely. Risks include uterine perforation. GnRH agonists are effective in reducing menstrual blood flow. and Asherman syndrome. causing amenorrhea in 4-6 weeks. although studies have shown that less than 50% of the endometrium is sampled during a D&C. Androgenic effects cause acne.

This procedure requires the use of a resectoscope (ie. and it requires time and skill but achieves an 84% satisfaction or success rate. It has the same requirements. Of patients. endometrial ablation o o • Roller-ball   o Roller-ball endometrial ablation essentially is the same as TCRE. ablation or resection preparation o o o • Endometrial   o A trial of medical therapy should have failed in patients considered for this therapy. the time required for the procedure (long). except that a heated roller ball is used to destroy the endometrium (instead of the wire loop). The endometrium should be properly sampled and evaluated before surgery. The laser is inserted into the uterus through the hysteroscope while transmitting energy through the distending media to warm and eventually coagulate the endometrial tissue. hysteroscope with a heated wire loop). Patients should be pretreated with danazol or a GnRH analogue for 4-12 weeks before surgery to atrophy the endometrium. Disadvantages include the expense of the equipment (high). and the risk of excessive fluid uptake from the distending media infusion and irrigating fluid.o Transcervical resection of the endometrium (TCRE) has been considered the criterion standard cure for menorrhagia for many years. and outcome success as TCRE. o o o . resulting in an overall success rate of nearly 80%. The primary risk is uterine perforation. 50% have amenorrhea and another 30% have hypomenorrhea. laser ablation o o • Endometrial   o Endometrial laser ablation requires Nd:YAG (neodymium-doped:yttrium aluminum garnet) laser equipment and optical fiber delivery system. risks. Success rates are similar to laser ablation techniques. reducing surgical difficulty and time. Satisfaction rates are equal to those of TCRE.

This procedure was developed and has been used in Europe since 1996 o o o • • Acute menorrhagia requires prompt medical intervention. Microwaves are selected so that they do not destroy beyond 6 mm in depth. It is proving to be as effective as TCRE.1-1. The mortality rate ranges from 0. and heated to 87   for 8 minutes.• Uterine   o balloon therapy A balloon catheter filled with isotonic sodium chloride solution is inserted into the endometrial cavity. Picture 3. This procedure is more expensive and results in greater morbidity than ablative procedures. This success rate is slightly higher than the other techniques described above. Risks include those usually associated with major surgery. Uterine balloon therapy cannot be used in irregular uterine cavities because the balloon will not conform to the cavity. but the rate is based on short-term studies. o o o • Microwave endometrial ablation alternative o Microwave endometrial ablation (MEA) uses high-frequency microwave energy to cause rapid but shallow heating of the endometrium. This is bleeding that will compromise an untreated patient (see Picture 1). Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. Long-term studies are in place but have not been completed because this technique has not been available for as long as the others. For instance. The morbidity rate usually is 40%. acute bleeding postpartum does not respond to progesterone therapy. and Picture 4). MEA requires 3 minutes of time and only local anesthetic. inflated.1 cases per 1000 procedures. Studies report a 90% satisfaction rate and a 25% amenorrhea rate.   . while anovulatory bleeding worsens with high-dose estrogen (see Picture 2. o o • Hysterectomy   o o Hysterectomy provides definitive cure for menorrhagia.

such as swelling. coadministration with ibuprofen might decrease effects of loop diuretics. Category D in third trimester of pregnancy. nephrotoxicity) B . stomatitis. interstitial nephritis. they might effectively decrease uterine blood flow. hyperkalemia. Prostacyclin is produced in increased amounts in menorrhagic endometrium.Block formation of prostacyclin.• Drug Category: Nonsteroidal anti-inflammatory drugs -.Used for relief of mild to moderate pain. Naprelan. Naprosyn) -. hyponatremia. leukopenia occurs rarely. Naproxen (Anaprox. persistent leukopenia. asthma. give at last 2 d and first 3 d of cycle. Because NSAIDs inhibit blood prostacyclin formation. 250-500 mg PO bid. and usually returns to normal during therapy. might increase serum lithium levels and risk of methotrexate toxicity (eg. peptic ulcer disease. an antagonist of thromboxane. coadministration with anticoagulants might prolong PT (watch for signs of bleeding). or any forms of angioedema. for a total of 5 d Not established Documented hypersensitivity. is transient. hives. bone marrow suppression. which is responsible for prostaglandin synthesis. urticaria. granulocytopenia. or thrombocytopenia warrants further evaluation and might require discontinuation Name Diclofenac (Cataflam) Initial: 100 mg PO once. and renal papillary necrosis might occur. active ulcer Drug   Adult Dose Pediatric Dose Contraindications Interactions Pregnancy Precautions Drug   Adult Dose Contraindications . then 50 mg PO tid Use in persons with allergic reaction to aspirin/NSAIDs. Inhibits Name inflammatory reactions and pain by decreasing activity of cyclooxygenase. recent GI bleeding or perforation. renal insufficiency Probenecid may increase toxicity of NSAIDs.Usually safe but benefits must outweigh the risks. acute renal insufficiency. patients with preexisting renal disease or compromised renal perfusion risk acute renal failure. active GI bleed. which is a substance that accelerates platelet aggregation and initiates coagulation.

Reduce pituitary production of gonadotropins and result in reduced LH and FSH with no ovulation. NSAIDs have produced an elevation of plasma lithium levels and a reduction in renal lithium clearance C . myocardial infarction. repeat monthly Not established Documented hypersensitivity. known or suspected breast cancer. concomitantly with ACE inhibitors. 1 tab PO qd for 3 wk. renal or liver injury. cerebral vascular disease. Ethinyl estradiol and a progestin derivative (Ovral. possibly. and. clinical studies and postmarketing observations show that NSAIDs can reduce the natriuretic effect of furosemide and thiazides in some patients. past or present liver tumors Hepatotoxicity might occur with concurrent administration of cyclosporine. during which a withdrawal bleed generally occurs. phenylbutazone. griseofulvin. followed by a week of inactive pills. and tetracyclines might influence efficacy of oral Drug   Adult Dose Pediatric Dose Contraindications Interactions . anaphylaxis. concomitant use of rifampin. active or inactive thrombophlebitis or thromboembolic disorders. Genora) -. concomitant administration of low-dose aspirin may result in increased rate of GI ulceration or other complications compared to use of NSAIDs alone. known or suspected genital cancer. and this response has been attributed to inhibition of renal prostaglandin synthesis. phenytoin sodium.Interactions Reports suggest that NSAIDs may diminish the antihypertensive effect of ACE inhibitors. Ovcon. ampicillin. coronary artery disease. or a past history of these disorders.Safety for use during pregnancy has not been established. Ortho-Novum.OCPs containing estrogen and progestin used to treat acute hemorrhagic uterine bleeding.Reduce Name secretion of LH and FSH from the pituitary by decreasing amount of GnRH. pregnancy. Pregnancy Precautions • GI bleeding. barbiturates. pregnancy category D if given at third trimester Drug Category: Combination oral contraceptives -. history of cholestatic jaundice in pregnancy or jaundice with prior pill use.

breasts. making control of hyperlipidemia more difficult (observe closely). documentation of recent Pap smear test.Contraindicated in pregnancy Complete physical examination. migraine.Provera: Short-acting synthetic progestin.Occasional anovulatory bleeding that is not profuse or prolonged can be treated with progestins. with resultant pancreatitis Discontinue if jaundice develops Contact lens wearers with visual changes should be examined by ophthalmologist Patients might develop hypertension secondary to increase in angiotensinogen production (reevaluate blood pressure approximately 3 mo after initiating therapy in all patients) • Drug Category: Progestins -. or renal or cardiac dysfunction History of psychic depression might be aggravated (observe patient closely) Precautions Progestin compounds might elevate LDL levels. abdomen. Is active against hyperplasia without significantly altering serum lipid levels. Have partial . converting estradiol to the less-active estrone. and pelvic organs.contraceptives and increase amount of breakthrough bleeding and menstrual irregularity Pregnancy X . antiestrogens given in pharmacologic doses. Endometrium is maintained in an atrophic state. lowering HDL) Megestrol acetate: May be substituted for Provera. repeat physical examination annually as long as patient is on hormonal therapy Oral contraceptives can cause fluid retention (address any condition aggravated by this factor) Monitor patients with epilepsy. Works as an antiestrogen by minimizing estrogen effects on target cells. Derivatives of 19-nortestosterone: Potent progestins used in oral contraceptives. Drug   Name Medroxyprogesterone (Provera)/megestrol acetate/19-nortestosterone derivative -. and family history recommended. pay special attention to blood pressure. Effective against hyperplasia and has modest effects on serum lipids (ie. certain forms of congenital hypertriglyceridemia might be aggravated by oral contraceptives. asthma. Inhibit estrogen-receptor replenishment and activate 17-hydroxysteroid dehydrogenase in endometrial cells.

active or past history of thrombophlebitis. perform complete physical examination. or cerebral apoplexy (based on past experience with combination oral contraceptive medications. with resultant hypogonadism. doses vary from 0. depression. repeat physical examination annually. which suppress gonadotropin release. liver dysfunction. and pelvic organs. renal or cardiac dysfunction. missed abortion. gonadotropin levels fall to castrate levels. little data suggest that progestin therapy used without estrogen is associated with an increased risk of thrombotic events) Decreases aminoglutethimide efficacy X .Contraindicated in pregnancy Adult Dose Pediatric Dose Contraindications Interactions Pregnancy Caution in asthma. monitor patients with epilepsy. After an initial gonadotropin release associated with rising estradiol levels.35 mg/pill depending on derivative Derivatives of 19-nortestosterone for atypical hyperplasia: 5 mg/d for 12 d once Not established Documented hypersensitivity. give special attention to blood pressure. Precautions breasts.Work by reducing concentration of GnRH receptors in the pituitary via receptor down-regulation and induction of postreceptor effects.androgenic properties and lower HDL cholesterol levels. progestins can cause fluid retention (address any condition aggravated by this factor). known or suspected malignancy of breast or genital tract. and history of psychic depression • Drug Category: Gonadotropin-releasing hormone agonists -. cerebral apoplexy. This form of medical castration is very . renal or cardiac dysfunction.075-0. thrombophlebitis. document recent Papanicolaou smear. migraine. and take family history before therapy. asthma. undiagnosed vaginal bleeding. thromboembolic disorders. Provera: 10 mg/d PO for 10 d monthly Provera for atypical hyperplasia: 10 mg/d PO for 12 d once Megestrol acetate: 40-80 mg PO for 10 d monthly Megestrol acetate for atypical hyperplasia: 40-80 mg PO for 12 d once Derivatives of 19-nortestosterone: Used in oral combination birth control pills. or thromboembolic disorders. abdomen.

markedly impaired hepatic function or porphyria Prolongation of PT occurs in patients who are on warfarin. Competes with androgen and progesterone at receptor level.Contraindicated in pregnancy Urinary tract obstruction. may cause menopauselike symptoms. thus breaking the ongoing cycle of abnormal bleeding in many anovulatory patients.Contraindicated in pregnancy Caution in renal. and testosterone X .Synthetic steroid analog with strong antigonadotropic activity (inhibits LH Name and FSH) and weak androgenic action. Use might stimulate erythropoiesis and clotting efficiency.5 mg IM monthly for 3-6 mo Not established Documented hypersensitivity. androgen effects may cause hirsutism. androstenedione. tumor flare. Danazol (Danocrine) -.5-7. carbamazepine levels might rise with concurrent use. may cause bone demineralization and/or reduction in HDL cholesterol if given for >6 mo • Drug Category: Androgens -. might interfere with laboratory determinations of DHEA. seizure disorders. 100-400 mg PO qd for 3 mo Not established Documented hypersensitivity.Certain androgenic preparations have been used historically to treat mild-to-moderate bleeding. or decreased Drug   Adult Dose Pediatric Dose Contraindications Interactions Pregnancy Precautions . resulting in amenorrhea within 3 mo. acne. monitor patients for weakness and Precautions paresthesias. or cardiac insufficiency and in seizure disorders. Alters endometrial tissue so that it becomes inactive and atrophic. lowering of voice.effective in inducing amenorrhea.Suppresses ovarian and testicular steroidogenesis by decreasing LH and FSH levels. hepatic (may elevate serum transaminase levels). 3. particularly in ovulatory patients with abnormal uterine bleeding. Drug   Adult Dose Pediatric Dose Contraindications Interactions Pregnancy Name Leuprolide (Lupron) -. breastfeeding. and bone pain may occur. undiagnosed vaginal bleeding and spinal cord compression None reported X .

may cause platelet aggregation in von Willebrand type IIB • Drug Category: Estrogens -. history of thrombophlebitis. Estrogen also induces formation of progesterone receptors. profuse bleeding.Indicated in patients with thromboembolic disorders. or thromboembolic disorders.5 mg PO q6h for a maximum of 48 h Not established Documented hypersensitivity. Appropriate long-term therapy can be administered once the acute episode has passed. factor IV. Drug   Adult Dose Pediatric Dose Contraindications Interactions Pregnancy Avoid overhydration in patients using desmopressin to benefit from its hemostatic Precautions effects. platelet-type von Willebrand disease Coadministration with demeclocycline and lithium decrease effects. 2.Usually safe but benefits must outweigh the risks.Has been used to treat Name abnormal uterine bleeding in patients with coagulation defects.Effective in controlling acute. thrombosis. Desmopressin (DDAVP) -. 0. and factor X in blood and platelet aggregation and capillary permeability.Only controls bleeding acutely but does not treat Name underlying cause. Transiently elevates factor VIII and von Willebrand factor. Conjugated equine estrogen (Premarin) -. Acute bleeding: 25 mg IV q4h for a maximum of 48 h.• breast size Drug Category: Arginine vasopressin derivatives -. or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or Drug   Adult Dose Pediatric Dose Contraindications . known or suspected pregnancy. undiagnosed abnormal genital bleeding. breast cancer. making subsequent treatment with progestins more effective.3 mcg/kg in 50 mL NS IV push (15 min) Not established Documented hypersensitivity. Exerts a vasospastic action on capillary bleeding by affecting the level of fibrinogen. fludrocortisone and chlorpropamide increase effects B . active thrombophlebitis.

Education: Patient   • Reassure patients that most bleeding stops.Contraindicated in pregnancy Certain patients may develop undesirable manifestations of excessive estrogenic stimulation (eg. loss of seizure control has been noted when administered concurrently with hydantoins X . medication dosing. and follow-up care. but not immediately. coadministration of barbiturates. prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia Interactions Pregnancy Precautions Complications: • Treatment must be individualized to treat each patient's specific symptoms. including noncompliance. diagnosis. abnormal or excessive uterine bleeding. including expectations and adverse effects. rifampin. • • Prognosis: • With proper workup. mastodynia). Many patients appreciate reassurance that they do not have cancer and are not alone in their plight. dosing. have the patient keep a menstrual calendar to better assess the resulting bleeding pattern. and patient compliance can play major roles. and other agents that induce hepatic microsomal enzymes may reduce estrogen levels. Provide literature on the treatment of choice. and comorbid conditions. may cause some degree of fluid retention (exercise caution). Cost. If a specific treatment fails. prognosis is excellent. • .prostatic malignancy) May reduce hypoprothrombinemic effect of anticoagulants. diagnosis. investigate all possibilities. patient age. If bleeding does not subside within the expected time frame. treatment. pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogeninduced inactivation of hepatic P450 enzyme.

including noncompliance. especially if ovulation is induced by the cycling of the progesterone. All medications and procedures must be administered only after informed consent of all benefits and risks. Medical/Legal Pitfalls: • Every patient presenting with uterine bleeding should first undergo pregnancy testing. Many patients appreciate reassurance that they do not have cancer and are not alone in their plight. Every high-risk or postmenopausal patient with uterine bleeding first must be evaluated for endometrial or other gynecological malignancy. Threatened or incomplete abortion. but not immediately. Provide literature on the treatment of choice. Pregnancy is possible. dosing. treatment. If bleeding does not subside within the expected time frame. including expectations and adverse effects. prognosis is excellent. ectopic pregnancy. investigate all possibilities. Cost. If a specific treatment fails. Patient Education: • Reassure patients that most bleeding stops. they must be informed that this is not a form of birth control. diagnosis. diagnosis. and patient compliance can play major roles. • • Medical/LegalPitfalls: . When treating patients with progestin therapy of any form.• Reassure patients who experience a treatment failure that other options are available. and comorbid conditions. • • Prognosis: • With proper workup. medication dosing. or retained products of conception must be considered before any imaging studies may be ordered. have the patient keep a menstrual calendar to better assess the resulting bleeding pattern. • • • Complications: • Treatment must be individualized to treat each patient's specific symptoms. patient age. Reassure patients who experience a treatment failure that other options are available. and follow-up care.

When treating patients with progestin therapy of any form. ectopic pregnancy. or retained products of conception must be considered before any imaging studies may be ordered. Threatened or incomplete abortion. they must be informed that this is not a form of birth control. Every high-risk or postmenopausal patient with uterine bleeding first must be evaluated for endometrial or other gynecological malignancy. All medications and procedures must be administered only after informed consent of all benefits and risks.• Every patient presenting with uterine bleeding should first undergo pregnancy testing. Pregnancy is possible. • • • . especially if ovulation is induced by the cycling of the progesterone.