Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Menorrhagia Clinical Presentation

  • Author: Julia A Shaw, MD, MBA, FACOG; Chief Editor: Michel E Rivlin, MD  more...
 
Updated: Nov 03, 2015
 

History

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 that should be included are discussed below/

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.

Patient 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.

Next

Physical

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.
Previous
 
 
Contributor Information and Disclosures
Author

Julia A Shaw, MD, MBA, FACOG Assistant Professor and Residency Program Director, Department of Obstetrics and Gynecology, Yale School of Medicine; Medical Director, Yale-New Haven Hospital Women's Center

Julia A Shaw, MD, MBA, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Association for Physician Leadership, Connecticut State Medical Society, AAGL, North American Menopause Society

Disclosure: Nothing to disclose.

Coauthor(s)

Howard A Shaw, MD, MBA Clinical Professor of Obstetrics and Gynecology, Yale University School of Medicine; Medical Director, Department of Women's and Children's Services, Yale-New Haven Hospital, Saint Raphael Campus

Howard A Shaw, MD, MBA is a member of the following medical societies: American Medical Association, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Connecticut State Medical Society, American Urogynecologic Society, American Society for Colposcopy and Cervical Pathology, American College of Healthcare Executives, International Urogynaecology Association, American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, American Association for Physician Leadership, Southern Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT)

A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, Association of Military Surgeons of the US, American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Thomas Michael Price, MD Associate Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, Phi Beta Kappa, Society for Reproductive Investigation, Society for Reproductive Endocrinology and Infertility, American Society for Reproductive Medicine

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.

References
  1. Tucker ME. Levonorgestrel system eases effects of menorrhagia. Medscape Medical News. Jan 09, 2013. Available at http://www.medscape.com/viewarticle/777406. Accessed: Jan 14, 2013.

  2. Gupta J, Kai J, Middleton L, et al. Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med. 2013 Jan 10. 368(2):128-37. [Medline].

  3. DeCherney A, Polan ML. Hysteroscopic management of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol. 1983 Mar. 61(3):392-7. [Medline].

  4. Chullapram T, Song JY, Fraser IS. Medium-term follow-up of women with menorrhagia treated by rollerball endometrial ablation. Obstet Gynecol. 1996 Jul. 88(1):71-6. [Medline].

  5. Meyer WR, Walsh BW, Grainger DA, et al. Thermal balloon and rollerball ablation to treat menorrhagia: a multicenter comparison. Obstet Gynecol. 1998 Jul. 92(1):98-103. [Medline].

  6. Garza-Leal J, Pena A, Donovan A, et al. Clinical evaluation of a third-generation thermal uterine balloon therapy system for menorrhagia coupled with curettage. J Minim Invasive Gynecol. 2010 Jan-Feb. 17(1):82-90. [Medline]. [Full Text].

  7. Goldrath MH. Evaluation of HydroThermAblator and rollerball endometrial ablation for menorrhagia 3 years after treatment. J Am Assoc Gynecol Laparosc. 2003 Nov. 10(4):505-11. [Medline].

  8. [Guideline] ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 81, May 2007. Obstet Gynecol. 2007 May. 109(5):1233-48. [Medline].

  9. Lethaby A, Hickey M, Garry R. Endometrial destruction techniques for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005 Oct 19. CD001501. [Medline]. [Full Text].

  10. Learman LA, Summitt RL Jr, Varner RE, et al. Hysterectomy versus expanded medical treatment for abnormal uterine bleeding: clinical outcomes in the medicine or surgery trial. Obstet Gynecol. 2004 May. 103(5 Pt 1):824-33. [Medline].

  11. Wright RC. Hysterectomy: past, present, and future. Obstet Gynecol. 1969 Apr. 33(4):560-3. [Medline].

  12. Showstack J, Lin F, Learman LA, et al. Randomized trial of medical treatment versus hysterectomy for abnormal uterine bleeding: resource use in the Medicine or Surgery (Ms) trial. Am J Obstet Gynecol. 2006 Feb. 194(2):332-8. [Medline].

  13. Chen YJ, Li YT, Huang BS, Y, et al, for the Taiwan Association of Gynecology Systematic Review Group. Medical treatment for heavy menstrual bleeding. Taiwan J Obstet Gynecol. 2015 Oct. 54 (5):483-8. [Medline].

  14. Hallberg L, Nilsson L. Determination of menstrual blood loss. Scand J Clin Lab Invest. 1964. 16:244-8. [Medline].

  15. Goldrath MH. Hysteroscopic endometrial ablation. Obstet Gynecol Clin North Am. 1995 Sep. 22(3):559-72. [Medline].

  16. Fraser IS, Warner P, Marantos PA. Estimating menstrual blood loss in women with normal and excessive menstrual fluid volume. Obstet Gynecol. 2001 Nov. 98(5 Pt 1):806-14. [Medline].

  17. Warner PE, Critchley HO, Lumsden MA, Campbell-Brown M, Douglas A, Murray GD. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. Am J Obstet Gynecol. 2004 May. 190(5):1216-23. [Medline].

  18. Lentz GM. Abnormal uterine bleeding. Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby; 2007. 915-32.

  19. Glasser MH, Zimmerman JD. The HydroThermAblator system for management of menorrhagia in women with submucous myomas: 12- to 20-month follow-up. J Am Assoc Gynecol Laparosc. 2003 Nov. 10(4):521-7. [Medline].

  20. Wilansky DL, Greisman B. Early hypothyroidism in patients with menorrhagia. Am J Obstet Gynecol. 1989 Mar. 160(3):673-7. [Medline].

  21. Collins JA, Schlesselman JJ. Hormone replacement therapy and endometrial cancer. Lobo RA, ed. Treatment of the Postmenopausal Woman: Basic and Clinical Aspects. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 1999. 503-12.

  22. [Guideline] James AH, Kouides PA, Abdul-Kadir R, et al. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. 2009 Jul. 201(1):12.e1-8. [Medline].

  23. Noorhasan DJ, Weiss G. Perimenarchal menorrhagia: evaluation and management. J Pediatr. 2010 Jan. 156(1):162. [Medline]. [Full Text].

  24. Kadir RA, Economides DL, Sabin CA, et al. Frequency of inherited bleeding disorders in women with menorrhagia. Lancet. 1998 Feb 14. 351(9101):485-9. [Medline].

  25. Dodson MG. Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia. J Reprod Med. 1994 May. 39(5):362-72. [Medline].

  26. Dijkhuizen FP, Mol BW, Brolmann HA, Heintz AP. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer. 2000 Oct 15. 89(8):1765-72. [Medline].

  27. Shaw RW. Assessment of medical treatments for menorrhagia. Br J Obstet Gynaecol. 1994 Jul. 101 Suppl 11:15-8. [Medline].

  28. Jurema M, Zacur H. Menorrhagia. UpToDate. Available at http://bit.ly/fHJVtw. Accessed: March 29, 2009.

  29. Fraser IS, McCarron G. Randomized trial of 2 hormonal and 2 prostaglandin-inhibiting agents in women with a complaint of menorrhagia. Aust N Z J Obstet Gynaecol. 1991 Feb. 31(1):66-70. [Medline].

  30. Jensen JT, Parke S, Mellinger U, Machlitt A, Fraser IS. Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial. Obstet Gynecol. 2011 Apr. 117(4):777-87. [Medline].

  31. Andersson JK, Rybo G. Levonorgestrel-releasing intrauterine device in the treatment of menorrhagia. Br J Obstet Gynaecol. 1990 Aug. 97(8):690-4. [Medline].

  32. Rauramo I, Elo I, Istre O. Long-term treatment of menorrhagia with levonorgestrel intrauterine system versus endometrial resection. Obstet Gynecol. 2004 Dec. 104(6):1314-21. [Medline].

  33. FDA approves intrauterine device for heavy menstrual bleeding. PR Newswire. Available at http://bit.ly/eKOVjr. 2009 Oct 01; Accessed: October 5, 2009.

  34. Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010 Sep. 116(3):625-32. [Medline].

  35. Kim JY, No JH, Kim K, et al. Effect of myoma size on failure of thermal balloon ablation or levonorgestrel releasing intrauterine system treatment in women with menorrhagia. Obstet Gynecol Sci. 2013 Jan. 56(1):36-40. [Medline]. [Full Text].

  36. Gupta JK, Daniels JP, Middleton LJ, et al. A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial. Health Technol Assess. 2015 Oct. 19 (88):1-118. [Medline].

  37. Lukes AS, Moore KA, Muse KN, et al. Tranexamic acid treatment for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010 Oct. 116(4):865-75. [Medline].

  38. Nakamura K, Nakayama K, Ishikawa M, et al. Efficacy of multiple microwave endometrial ablation technique for menorrhagia resulting from adenomyosis. J Obstet Gynaecol Res. 2015 Nov. 41 (11):1769-72. [Medline].

  39. Lethaby A, Hickey M, Garry R, Penninx J. Endometrial resection / ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev. 2009 Oct 7. CD001501. [Medline].

  40. Fischer F, Klapdor R, Gruessner S, Ziert Y, Hillemanns P, Hertel H. Radiofrequency endometrial ablation for the treatment of heavy menstrual bleeding among women at high surgical risk. Int J Gynaecol Obstet. 2015 Nov. 131 (2):123-8. [Medline].

  41. Roberts TE, Tsourapas A, Middleton LJ, et al. Hysterectomy, endometrial ablation, and levonorgestrel releasing intrauterine system (Mirena) for treatment of heavy menstrual bleeding: cost effectiveness analysis. BMJ. 2011 Apr 26. 342:d2202. [Medline]. [Full Text].

  42. Maybin JA, Critchley HO. Menstrual physiology: implications for endometrial pathology and beyond. Hum Reprod Update. 2015 Nov. 21 (6):748-61. [Medline].

 
Previous
Next
 
Acute menorrhagia requires prompt medical intervention. This is bleeding that will compromise an untreated patient.
Successful treatment of chronic menorrhagia is highly dependent on a thorough understanding of the exact etiology. For instance, acute bleeding postpartum does not respond to progesterone therapy, while anovulatory bleeding worsens with high-dose estrogen.
Flow chart continued from the previous image.
Flow chart continued from the previous 2 images.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.