23

Menorrhagia

WHAT IS IT?
Menorrhagia is excessive menstrual bleeding. It can be described
as menses that lasts longer than 7 days; menses that occurs more
frequently than every 21 days; menses that is heavy enough to
require lifestyle modifications; excessive clotting; or intermen-
strual bleeding.

WHO GETS IT?

Women of childbearing age, although it is more commonly seen
in women in their thirties and forties.

ETIOLOGY
Common causes of menorrhagia include the following:
 Fibroids
 Endometriosis
 Abortion or threatened miscarriage
 Use of some intrauterine devices (IUDs) for birth control

Clinical Pearl
Progesterone-containing IUDs such as the Mirena IUD may decrease
menstrual flow.

 Pelvic inflammatory disease (PID)

 Uterine polyps
 Congenital uterine anomalies
 Stress

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158 Mosby’s Guide to Women’s Health: A Handbook for Health Professionals

 Insufficient nutrient intake

 Some birth control pills
 Abnormal hormonal fluctuations
 Increased prostaglandin activity
 Medications such as the anticoagulants and some anti-
inflammatory agents may contribute to prolonged or heavy
menstrual bleeding

SIGNS AND SYMPTOMS

 Excessive menstrual bleeding that may or may not be accom-
panied by pain

DIAGNOSIS
 Careful, comprehensive history
 Assessment for iron deficiency anemia
 Assessment for reproductive tract cancers
 Pelvic examination and Papanicolaou (Pap) smear
 Complete blood count (CBC)
 Endometrial biopsy
 Dilation and curettage (D&C) if the biopsy is normal and
bleeding persists
 Ultrasound to evaluate for fibroids and ovarian cysts/tumors
 Hysterosalpingogram (HSG)
 Hysteroscopy

MANAGEMENT
Identify and manage the causative factor:
 Lifestyle
 Diet
 Foods high in beta-carotene, including watermelon and oth-
er brightly colored fruits and vegetables such as sweet pota-
toes, red yams, peppers, carrots, beets, and squash
 Foods high in iron, including fish, poultry, red meats, green
leafy vegetables, and legumes

Spinal Manipulation
Spinal manipulation at the thoracolumbar junction and sacrum.
Anecdotal evidence has reported shorter bleeding times with
adjustment at S2 following cervical cauterization.
 23 Menorrhagia 159

Medications
Medications currently used for menorrhagia include the follow-
ing:
 Birth control pills help regulate the timing and intensity of
each cycle. Either the combined pill or the progesterone-only
pills may be used. These help maintain a uterine lining that is
less vascular, resulting in lighter periods.
 Depo-Provera, the progestin-only birth control injection ad-
ministered every 3 months, reduces the thickness of the endo-
metrial lining, thereby reducing blood loss.
 Gonadotropin-releasing hormone (GnRH) agonists such as
Lupron and Nafarelin create a menopausal state by depleting
follicle-stimulating hormone (FSH) and luteinizing hormone
(LH) secretion from the pituitary, thereby reducing or elimi-
nating menstrual flow. GnRH agonists are more commonly
used to minimize blood loss during myomectomy and rarely
are used as a long-term strategy for menorrhagia management.
 The nonsteroidal antiinflammatory drugs (NSAIDs) and the
prostaglandin synthetase inhibitors such as Naprosyn, Ibupro-
fen, Advil, and Motrin reduce bleeding and modulate the pain
sometimes associated with menorrhagia.
 Antibiotics are administered to treat menorrhagia caused by PID.

PROCEDURES
 Endometrial ablation to destroy the entire internal lining of
the uterus
 Endometrial resection to remove the lining of the uterus
 Insertion of progestin-releasing IUDs, which release small
amounts of levonergesterel locally into the uterus, thereby
reducing menstrual blood loss
 Laparoscopy or myomectomy if fibroids or endometriosis are
identified as the causative factor
 Hysterectomy or hysterectomy with bilateral salpingo-oopho-
rectomy

Clinical Pearl
The most common complication of menorrhagia is iron deficiency
anemia. Iron is needed by the blood to make hemoglobin, the
160 Mosby’s Guide to Women’s Health: A Handbook for Health Professionals

oxygen-carrying component of red blood cells. Menorrhagia is the most

common cause of anemia in premenopausal women.
Symptoms of iron deficiency anemia include weakness, fatigue, shortness
of breath, brittle nails, tinnitus, headaches, rapid heart rate, light-
headedness, memory loss, general mental confusion, irritability, pale
skin, and restless legs syndrome.

Management of iron deficiency anemia may require the

following:
 Dietary alterations (foods high in iron, including liver and
other red meats, green leafy vegetables, fish, beans, fortified
cereals and breads, chicken, and turkey)
 Iron supplementation (up to 45 mg daily)
 Vitamin C to enhance iron absorption
 The herb yellow dock is a good source of iron

Clinical Pearl
Menorrhagia in a postmenopausal woman who is not on combined
hormonal replacement therapy is always a cause for concern because of
the risk for vaginal or uterine cancer.