Obstetrics & Gynaecology
Question 10 of 30
A 34 year old woman presents to the Emergency Department with a 3 year history of menorrhagia. She is otherwise well with no past medical history. She has no intermenstrual or postcoital bleeding. What is the most common cause of menorrhagia?
Answer:
In almost 50% of women with menorrhagia, no cause is identified — this is classified as dysfunctional uterine bleeding.Menorrhagia
Obstetrics & Gynaecology
Last Updated: 17th March 2021
Menorrhagia is excessive (heavy) menstrual blood loss that occurs regularly (every 24 to 35 days) which interferes with a woman's physical, emotional, social, and material quality of life. Excessive menstrual blood loss is classified as 80 mL or more and/or a duration of more than 7 days. Excessive menstrual bleeding is also defined as the need to change menstrual products every one to two hours, passage of clots greater than 2.5 cm, and/or 'very heavy' periods as reported by the woman.
Causes
In almost 50% of women with menorrhagia, no cause is identified — this is classified as dysfunctional uterine bleeding. In other women, the aetiology can be classified by the cause.
- Uterine and ovarian pathologies
- Uterine fibroids
- Endometriosis and adenomyosis
- Pelvic inflammatory disease and pelvic infection
- Endometrial polyps
- Endometrial hyperplasia or carcinoma
- Polycystic ovary syndrome
- Systemic diseases and disorders
- Coagulation disorders (for example von Willebrand disease)
- Hypothyroidism
- Diabetes mellitus
- Hyperprolactinaemia
- Liver or renal disease
- Iatrogenic causes
- Anticoagulant treatment
- Chemotherapy
- Herbal supplements (for example ginseng, ginkgo, and soya)
- Intrauterine contraceptive device
Investigations
- Arrange a full blood count in all women — to rule out iron deficiency anaemia
- For women with suspected submucosal fibroids, polyps, or endometrial pathology — offer a hysteroscopy or ultrasound to assess for a cause of menorrhagia
- Arrange other investigations as suggested by history and clinical findings, for example:
- A vaginal or cervical swab — if an infection is suspected.
- Thyroid function tests — if there are features of hypothyroidism.
- Tests for coagulation disorders (for example von Willebrand disease) — in women who have had heavy menstrual bleeding since menarche, and a personal or a family history of a coagulation disorder
Management
- For women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis:
- Consider a levonorgestrel intrauterine system (LNG-IUS) as the first-line treatment.
- If an LNG-IUS is declined or unsuitable, consider the following pharmacological treatments:
- Non-hormonal: tranexamic acid or a non steroidal anti-inflammatory drug (NSAID).
- Hormonal: combined hormonal contraception (CHC) or a cyclical oral progestogen (such as oral norethisterone).
- If treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider referral to a specialist for:
- Investigations to diagnose the cause of menorrhagia, if needed, taking into account any investigations the woman has already had, and
- Alternative treatment choices, including pharmacological options not already tried and surgical options (second-generation endometrial ablation and hysterectomy).
- For women with fibroids of 3 cm or more in diameter:
- Consider specialist referral for additional investigations and consideration of treatment options.
- If pharmacological treatment is needed while the woman is awaiting treatment or referral appointment, offer tranexamic acid and/or an NSAID.
- Taking into account the size, location, and number of fibroids; the severity of the symptoms; the presence of any comorbidities; and the preference of the woman, secondary care treatment options for women with fibroids of 3 cm or more in diameter include:
- Pharmacological treatment — hormonal (LNG-IUS, CHC, or cyclical oral progestogens) or non-hormonal (NSAIDs or tranexamic acid).
- Uterine artery embolisation.
- Surgery — myomectomy, hysterectomy, or second-generation endometrial ablation (considered for women with menorrhagia and fibroids of 3 cm or more in diameter who meet the criteria specified in the manufacturers' instructions).
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
