Menorrhagia



Background

Menorrhagia (Heavy Menstrual Bleeding):

  • Regularly excessive menstrual blood loss that affects the physical, social, emotional or material quality of life of the patient

Causes

Structural Non Structural
Polyp Coagulation Disorder
Adenomyosis Ovulatory Dysfunction
Leiomyoma (fibroid) Endometrial (primary disorder of mechanisms regulating haemostasis)
Malignancy/Hyperplasia Infection/Iatrogenic (medication)
  Not Yet Known

*Red Flags

  1. > 45 yo with new/worsening menorrhagia
  2. Obese
  3. On Tamoxifen
  4. Persistent intermenstrual or postcoital bleeding
  5. Polycystic Ovary Syndrome (PCOS)

Clinical

Women reporting menorrhagia should have:

  1. A detailed clinical history:
    1. How many days is the menstrual bleeding for and how often does it occur?
    2. Passage of large clots, flooding of blood, the need for frequent change of protection, the use of double protection, frequent staining of clothes or bedclothes and bleeding which is socially restrictive all indicate significant menorrhagia.
    3. Symptoms of anaemia such as breathlessness and postural dizziness.
    4. Progressively-occurring anaemia in women with chronic menorrhagia is often not associated with clinical symptoms of anaemia.
    5. Accompanying symptoms relating to possible causes of menorrhagia should be explored. These include pelvic pressure and urinary frequency, pelvic pain / dyspareunia, prolonged bleeding following minor abrasions.
    6. Symptoms suggestive of hypothyroidism.
  2. Physical examination (as the ED allows) – abdominal examination at the very least.
  3. If an abdominal or pelvic mass is found on exam. US imaging should be performed.
  4. FBC.
  5. TFTs if symptomatic.

Management

  1. If examination abnormal or any red flags* present, refer to O&G as an outpatient. Follow attached link for referral pathway.
  2. If examination normal, you can provide either hormonal or non hormonal treatment (depending on the patient's desire for pregnancy) and discharge to the care of the GP. See the attached guideline and flowchart.
Pregnancy desired – Non Hormonal: Pregnancy not desired – Hormonal:
TXA Acid PO 500mg BD up to 1g QDS (to last as long as the bleeding – GP to continue as needed) COCP
Mefenamic Acid 500mg up to TDS (GP to continue as needed) Desogestrel 75mcg POP
  TXA & Mefenamic Acid (as for if pregnancy desired)
  Oral Progestogens
  Mirena
  Depo-Provera


Content by Dr Robyn Powell, Dr Íomhar O' Sullivan. Last review Dr ÍOS 20/04/22.