Managing menorrhagia

May 1, 2005

An expert examines the evidence for the effectiveness of a wide array of drugs and surgical approaches used to treat, and overtreat, heavy menstrual bleeding.

Are too many hysterectomies still being performed? Menstrual complaints, which impair the quality of life for many reproductive-aged women, are one of most common reasons for referral to specialists, accounting for one third of a gynecologist's outpatient workload. Unfortunately, the number of women with menstrual complaints who are managed surgically continues to climb, especially among women between 35 and 44 years. Hysterectomy remains the leading major surgical procedure performed in the United States. In fact, it's estimated that one out of every four American women will eventually have her uterus removed.

Most of these hysterectomies are performed in premenopausal women for menstrual complaints. That takes a heavy toll in terms of days missed from work annually-which in turn puts a heavy financial burden on society. 1 These statistics only serve to reinforce the need to identify medical approaches to management. But despite this urgent need, among those women who do begin medical treatment, only a few choose to continue, even though 80% of women have no clear-cut pelvic pathology and more than one third of hysterectomies performed for complaints of heavy bleeding involve removing a uterus without pathology.2-4

To date no researchers have been able to establish a correlation between endometrial and myometrial histology in women with objective normal and excessive blood loss. Furthermore, there are no endocrine data to indicate gross ovarian or hypothalamic-pituitary dysfunction in women who complain of heavy regular periods.

Defining menorrhagia Menorrhagia is defined subjectively as heavy vaginal bleeding over consecutive menstrual cycles. The average woman loses about 35 mL of blood during menstruation. Objectively measured excess menstrual blood loss is blood loss greater than 80 mL per month, which is the 90th percentile. Iron deficiency may develop at losses of 60 mL or greater.5 Most menstrual blood is lost during the first 3 days of menstruation-a pattern that is maintained whether menstrual blood loss is normal or excessive.

Most women who present with heavy menstrual bleeding are between ages 30 and 49. As most ob/gyns know, the subjective complaint of heavy blood loss may be inconsistent with objectively measured menstrual blood losses.6 But most of the time it's impractical for clinicians to evaluate the severity of the condition by objective assessment of menstrual blood loss.

The clinical history can sometimes provide useful clues and signal the presence of heavy menstrual bleeding. In a recent survey of more than 900 women with menstrual complaints, five clinical features were most strongly associated with blood loss volume: (1) rate of changing sanitary protection during full flow, (2) the total number of products used, (3) the need to change during the night, (4) the size of clots, and (5) poor iron status.7

When managing menorrhagia, clinicians should strive to make improving a patient's quality of life their primary aim, choosing medical management as the initial treatment (which is the only option for women who wish to have children). Although a large number of drugs are available for management, the lack of evidence to support many of these approaches may explain the marked variations in practice and the difficulty of identifying the most appropriate therapy.8 Unacceptable side effects and problems getting patients to adhere to therapy further undermine the success of medical treatment. My purpose here is to look at the various medical and surgical options and assess which are most effective.

What causes menorrhagia? Leiomyomata, endometrial polyps, adenomyosis, and pelvic infections have all been linked to abnormal and excessive menstrual blood loss. At least half of all women with a menstrual loss greater than 200 mL per month will have fibroids, which is beyond the scope of this short review, but covered in more detail elsewhere.9,10 Although the relationship between intrauterine and endometrial polyps is unclear, an association with heavy bleeding is recognized.