Menorrhagia Clinical Presentation

Symptoms related by a patient with menorrhagia often can be more revealing than laboratory tests. Considering the lengthy list of possible etiologies that contribute to menorrhagia, taking a detailed patient history is imperative. Inquiries should include the following:

• Exclusion of pregnancy

  • This is the most common cause of irregular bleeding in women of reproductive age.
  • Pregnancy should be the first diagnosis to be excluded before further testing or medications are instituted.
• Quantity and quality of bleeding

  • Quantity is a very subjective issue when considering vaginal bleeding. Best estimates usually are the only source clinicians have available to consider. 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. 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.
  • Quality of bleeding involves the presence of clots and their size.
• Age

  • Young patients, from menarche to the late-teen years, most commonly have anovulatory bleeding due to the immaturity of their hypothalamic-pituitary axis. If bleeding does not respond to usual therapy in this age group, a bleeding disorder must be considered.
  • Women aged 30-50 years may have organic or structural abnormalities. Fibroids or polyps are frequent anatomical findings. Organic causes can be anything from thyroid dysfunction to renal failure.
  • Postmenopausal women with any uterine bleeding should receive an immediate workup for endometrial cancer.
  • Endometrial hyperplasia must be considered in women who are obese, aged 70 or older, nulliparous, or have diabetes.
• Pelvic pain and pathology

  • Knowing if a patient has any long-standing diagnosis or known pathology (eg, fibroids) is helpful.
  • Records from other physicians or hospitalizations may prevent redundancy in ordering lab work or diagnostic imaging.
• Menses pattern from menarche

  • If a young patient has had irregular menses since menarche, the most common etiology of her bleeding is anovulation.
  • Anovulatory bleeding is most common in young girls (aged 12-18 y) and common in obese females of any reproductive age.
  • If a patient's bleeding normally occurs at regular intervals and the irregularity is new in onset, pathology must be ruled out, regardless of age.
• Sexual activity

  • Simple vaginitis (eg, candidal, bacterial vaginosis) may cause intermenstrual bleeding, while gonorrhea and chlamydia may present with heavier bleeding attributed primarily to the copious discharge mixed with the blood.
  • Chlamydia is a common cause of postpartum endometritis, leading to vaginal bleeding in the weeks following a delivery.
  • A postpartum infection (eg, endometritis) also may be due to organisms unrelated to sexual activity.
• Contraceptive use (intrauterine device or hormones)

  • Commonly, an intrauterine device (IUD) causes increased uterine cramping and menstrual flow.
  • If a patient has recently discontinued birth control pills, she may return to her "natural" menses and report an increase in flow. This actually is normal because most oral birth control pills decrease the flow and duration of a woman's menses.
• Presence of hirsutism (polycystic ovarian syndrome)

  • These patients commonly are obese and in an anovulatory state. When they do have a period, it may be very heavy and cause concern for the patient.
  • The etiology of this is explained in the Introduction to this article.
• Galactorrhea (pituitary tumor): Any patient complaining of a milky discharge from either breast (while not pregnant, postpartum, or breastfeeding) needs a prolactin level to rule out a pituitary tumor.
• Systemic illnesses (hepatic/renal failure or diabetes)

  • As explained in the Introduction, organic diseases may affect either the hormonal or hematologic pathways that are involved in the manifestation of menorrhagia.
  • If either the hypothalamic-pituitary axis or the coagulation paths are disrupted, heavy bleeding may result.
• Symptoms of thyroid dysfunction: The alteration of the hypothalamic-pituitary axis may create either amenorrhea (hyperthyroidism) or menorrhagia (hypothyroidism).
• Excessive bruising or known bleeding disorders

  • This is especially important in a young patient who does not stop bleeding during her first menses.
  • This is a very common presentation for an undiagnosed bleeding disorder (von Willebrand disease) in a young girl.
• Current medications (hormones or anticoagulants)

  • Any medication that prolongs bleeding time may cause menorrhagia.
  • A patient treated with any progestin therapy may have a withdrawal bleed after cessation of the medication. This bleeding often is heavy and worrisome to patients if they are not forewarned.
• Previous medical or surgical procedures/diagnoses: This also is helpful in preventing duplication of testing.

The physical examination should be tailored to the differential diagnoses formulated by the results of the patient's history.

• Initial inspection should include evaluation for the following:

  • Signs of severe volume depletion (eg, anemia): This may help confirm the patient's history of very heavy bleeding and/or prompt immediate inpatient care.
  • Obesity: This is an independent risk factor for endometrial cancer. Adipose tissue is a locale for estrogen conversion. Therefore, the larger the patient, the more increased the risk (and the higher the unopposed estrogen level on the endometrium).
  • Signs of androgen excess (eg, hirsutism): This usually points to polycystic ovarian syndrome (PCOS), leading to anovulatory bleeding (see Presence of hirsutism).
  • Ecchymosis: This usually is a sign of trauma or a bleeding disorder.
  • Purpura: This also is a sign of trauma or a possible bleeding disorder.
  • Pronounced acne: This is a sign of PCOS.
• General examination should include evaluation of the following:

  • Visual fields
  • Bleeding gums
  • Thyroid evaluation
  • Galactorrhea
  • Enlarged liver or spleen
• Pelvic examination should evaluate for the presence of external genital lesions.
• Vaginal/cervical discharge: Look for a copious discharge indicating infection, and confirm the actual site of the bleeding (if present). Assess as follows:

  • Uterine size, shape, and contour: An enlarged irregularly shaped uterus suggests fibroids if the patient is aged 30-50 years. An enlarged uniformly shaped uterus in a postmenopausal patient with bleeding suggests endometrial cancer until proven otherwise.
  • Cervical motion tenderness: This is a common symptom of pelvic inflammatory disease (PID) that usually is caused by gonorrhea or chlamydia. This is an important diagnosis to exclude, especially in young nulliparous women, because it can lead to pelvic adhesions and infertility.
  • Adnexal tenderness or masses: This is especially concerning in patients older than 40 years. Ovarian cancer may present with intermenstrual bleeding as its only symptom. Rare but deadly ovarian tumors also can present in teenage girls. Any suspicion of an adnexal mass should prompt an immediate pelvic ultrasound.

Etiologies of menorrhagia are divided into 4 categories, organic, endocrinologic, anatomic, and iatrogenic.

• Organic causes of menorrhagia include infection, bleeding disorders, and organ dysfunction.

  • Infections can be of any genitourinary origin. The aforementioned sexually transmitted diseases are of greater concern in the teenage and early adult population. Bleeding from the urethra or rectum always must be considered in the workup, especially in the postmenopausal woman who has negative findings after a workup for vaginal bleeding.
  • Coagulation disorders can evade diagnosis until menarche, when heavy menstrual bleeding presents as an unrelenting disorder. These include von Willebrand disease; factor II, V, VII, and IX deficiencies; prothrombin deficiency; idiopathic thrombocytopenia purpura (ITP); and thromboasthenia.^[9] See more on bleeding disorders below.
  • Organ dysfunction causing menorrhagia includes hepatic or renal failure. Chronic liver disease impairs production of clotting factors and reduces hormone metabolism (eg, estrogen). Either of these problems may lead to heavy uterine bleeding.
• Endocrine causes of menorrhagia include thyroid and adrenal gland dysfunction, pituitary tumors, anovulatory cycles, PCOS, obesity, and vasculature imbalance.

  • Both hypothyroidism and hyperthyroidism result in menorrhagia. Even subclinical cases of hypothyroidism produce heavy uterine bleeding in 20% of patients. Menorrhagia usually resolves with correction of the thyroid disorder.^[7]
  • Prolactin-producing pituitary tumors cause menorrhagia by disrupting (GnRH) secretion. This leads to decreased LH and FSH levels, which ultimately cause hypogonadism. Interim stages of menorrhagia result until hypogonadism manifests.
  • The most common etiology of heavy uterine bleeding is anovulatory cycles. The finding of menorrhagia at irregular intervals without any known organic etiology confirms the clinical diagnosis. This is most common in adolescent and perimenopausal populations.
  • The hallmarks of PCOS are anovulation, irregular menses, obesity, and hirsutism. Insulin resistance is common and increases androgen production by the ovaries.
  • Hyperinsulinemia is a direct consequence of obesity. This overproduction of insulin leads to ovarian production of androgens, as occurs in PCOS.
  • 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.
• Anatomic etiologies for menorrhagia include uterine fibroids, endometrial polyps, endometrial hyperplasia, and pregnancy.

  • Fibroids and polyps are benign structures that distort the uterine wall and/or endometrium. Either may be located within the uterine lining, but fibroids may occur almost anywhere on the uterus.
  • The mechanism by which endometrial polyps or fibroids cause menorrhagia is not well understood. 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, causing pooling in the areas of the fibroid. Heavy pooling is thought to weaken the endometrium in that area, and break-through bleeding ensues.
  • Fibroids located within the uterine wall may inhibit muscle contracture, thereby preventing normal uterine attempts at hemostasis. This also is why intramural fibroids may cause a significant amount of pain and cramping. Fibroids may enlarge to the point that they outgrow their blood supply and undergo necrosis. This also causes a great deal of pain for patients.
  • Endometrial hyperplasia usually results from unopposed estrogen production, regardless of the etiology. Endometrial hyperplasia can lead to endometrial cancer in 1-2% of patients with anovulatory bleeding, but it is a diagnosis of exclusion in postmenopausal bleeding (average age at menopause is 51 y). If a woman takes unopposed estrogen (without progesterone), her relative risk of endometrial cancer is 2.8 compared to nonusers.^[10]
  • Iatrogenic causes of menorrhagia include IUDs, steroid hormones, chemotherapy agents, and medications (eg, anticoagulants).
  • IUDs can cause increased menstrual bleeding and cramping due to local irritation effects.
  • Steroid hormones and chemotherapy agents disrupt the normal menstrual cycle, which is restored easily upon cessation of the products.
  • Anticoagulants decrease clotting factors needed to cease any normal blood flow, including menses. This type of menorrhagia also is easily reversible.

Bleeding disorders

An international expert panel including obstetrician/gynecologists and hematologists has issued guidelines to assist physicians in better recognizing bleeding disorders, such as von Willebrand disease, as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder.^[11] Historically, a lack of awareness of underlying bleeding disorders has led to underdiagnosis in women with abnormal reproductive tract bleeding. The panel provided expert consensus recommendations on how to identify, confirm, and manage a bleeding disorder. An underlying bleeding disorder should be considered when a patient has any of the following:

• Menorrhagia since menarche
• Family history of bleeding disorders
• Personal history of 1 or more of the following:

  • Notable bruising without known injury
  • Bleeding of oral cavity or gastrointestinal tract without obvious lesion
  • Epistaxis greater than 10 minutes duration (possibly necessitating packing or cautery)

If a bleeding disorder is suspected, consultation with a hematologist is suggested.