When a woman comes to you saying that her periods are "heavy" she's "flooding" or she's passing clots, what do you normally do to assess and treat her? The purpose of this paper is to define normal menstruation and how to clinically assess menstrual flow. In addition, you will learn how to make a diagnosis of menorrhagia and some practical medical ways in which you can manage it. We are now providing guidance for managing very heavy menstrual flow in women who are premenopausal and differentiating it from the instructions for dealing with women who are in very early perimenopause or the early menopause transition.
What is the normal menstrual flow?
In a randomly selected group of premenopausal women, the median blood flow was about two tablespoons (30 ml, or six soaked regular sized sanitary products) in a whole period (1) (2). However the range of menstrual blood loss is huge—from 0.1 ml to 540 ml! Women that are taller, have had children and are in perimenopause have the heaviest flow (2). The usual length of menstrual bleeding is four to six days. The usual amount of blood loss is 10 to 35 ml. No one has similarly tracked normal menstrual flow in what CeMCOR calls “Very Early Perimenopause” when cycles are still regular. Thus we don’t know what is normal flow for that earliest phase of perimenopause.
Officially, flow of more than 80 ml per menstrual period is considered menorrhagia. 80% of women bleeding this heavily will have one or more laboratory evidences of iron deficiency (1). However, statistically, the maximum flow should be between 45 and 60 ml (9-12 soaked sanitary products) per cycle (2).
This is not very clearly known. Menorrhagia is most common in adolescence and in perimenopause—both are times of the lifecycle in which estrogen exposure exceeds and is out of balance with the amount of progesterone produced. In both perimenopause and adolescence ovulatory cycles are less prevalent, the amount of progesterone produced is less or the duration of progesterone production (luteal phase length) is short.
Most women with menorrhagia report regular periods and have been shown to have normal estrogen and progesterone levels. In a study using a dilatation and curettage surgery (D & C) for all women with heavy flow in Tasmania, the greatest prevalence (20%) was in women ages 40-44. None of those who were pre- or perimenopausal had endometrial cancer (3). That means a D & C is usually unnecessary. Another study with quantitative assessment of flow performed endometrial biopsies on all and showed a strong positive correlation between late luteal endometrial estrogen receptor numbers and measured blood loss (r =0.81, P < 0.01) (4). This suggests that menorrhagia is related to increased estrogen action prior to onset of flow.
In women ages 40 to 50, fibroids are commonly believed to cause menorrhagia. However more estrogen action and less progesterone production cause fibroid growth as well as increased endometrial thickness. Fibroids are benign tumors that grow in the myometrium; less than 10% are submucous, thus few are even close to the endometrial surface. Therefore about 90% of fibroid could not possibly influence to flow. Fibroids or uterine polyps (small nubbins of extra tissue) are rarely a reason for heavy flow or to assess and treat menorrhagia differently than for other causes. (The bottom line is—don’t order a uterine ultrasound).
In perimenopause, approximately 25% of women will have at least one episode of heavy flow—it usually occurs when cycles are regular or irregular and before the onset of skipped cycles. Perimenopause is a time of higher than normal estrogen levels and lower progesterone levels (5;6). Other studies have shown that ovulation is less consistent or short luteal phase cycles are more common in perimenopause (7).
Very rarely is menorrhagia caused by a primary bleeding disorder. In a highly selected population with menorrhagia that was carefully and repeatedly tested for clotting abnormalities, only 17% were found to have any bleeding disorder (8). Therefore, only when a patient has responded poorly to usual therapies or has a family history should investigations for a clotting defect be performed.
How can I assess vaginal blood loss based on history?
Taking a menstrual flow history is not easy. The studies by Hallberg and Cole referred to above had women collect all sanitary products during one or more cycles and then quantitatively (chemically) analyzed them for blood. This is not practical for clinical practice. Also, some women may not normally pay attention to their flow. Or they may change sanitary products solely for cleanliness. And most women don’t know what flow is normal. Remember that women may be frightened by heavy flow and passing clots—this may cause them to become quite dramatic. If a woman seems to be anxious and to exaggerate her flow but is normally matter-of-fact, don’t discount her report.
Ask your patient to be specific in telling you about her flow—you need to know how many normal-sized pads and tampons she soaks on the first day, the heaviest day and a usual day of flow. Also you need to know how many days she bleeds. (This can be prospectively assessed if she will keep the Menstrual Cycle Diary or Daily Perimenopause Diary for a cycle or two.) Each soaked normal-sized pad or tampon holds approximately five millilitres of blood. To calculate the approximate amount of blood loss multiply the number of soaked normal-sized pads or tampons in a whole cycle by five to determine the millilitres of blood lost. A maxi-tampon or pad probably holds 10ml. Sixteen soaked normal-sized sanitary products used in one flow means a blood loss of 80 ml—your patient has menorrhagia. Normal flow is two to six soaked sanitary products a period.
Heavy flow and "flooding" can be better managed using a menstrual cup than pads or tampons. It is important to recommend one of the cups, such as DivaCup®, that has blood flow measurement markings at 15ml and 30ml, to help you and your patient better calculate blood loss. When no pad is thick enough or tampon big enough to prevent leaks, the menstrual cup works and can safely not be changed for 8-12 hours.
What laboratory tests will help assess heavy flow?
The first thing is to order a hemoglobin and hematocrit. If you get a history of ongoing heavy flow, or use of iron therapy, then assessment of ferritin, or the storage form of iron, is also needed. Only if she reports a family history of a bleeding disorder or personal excess bleeding with surgery should tests of the coagulation system be ordered and then not initially. If her period was late or she could be pregnant, do a pregnancy test—she could be having a miscarriage.
What can I do immediately if my patient calls telling me she is flowing heavily?
The first thing is to assess her amount of flow using her history of soaked sanitary products or volume loss from a menstrual cup. Next you need to know whether or not she has postural symptoms (dizzy or palpitations with standing). Finally, reassure her that you and she will work together to solve the heavy bleeding problem.
If she describes very heavy flow and especially if she has any postural symptoms, instruct her to drink several extra cups of salty fluids such as tomato or vegetable juices or bouillon type soups. Next tell her to take at least one tablet (200 mg) of ibuprofen with every meal on every heavy flow day. (If she is having dysmenorrhea then the ibuprofen, to be effective for cramps, must be taken frequently enough to stay ahead of the pain.) Non-steroidal anti-inflammatories decrease the amount of flow by 25-50% by altering the endometrial prostaglandin balance (9). Also have her start taking one tablet of iron a day. If her ferritin is low or if hemoglobin or hematocrit are low she should continue this for the full year that are necessary for her to replete her iron stores.
You will need to arrange for her to have an urgent assessment of her blood count and iron stores. You also need to examine her and should do both in the same visit. You can measure blood pressure and pulse after she has been lying down and resting for five minutes and then after one and three minutes of quiet standing. Remember that the maximum normal increase in pulse rate with standing is 20 beats a minute. That is the most likely abnormal finding in a young person with volume depletion.
It is a good time to do a pelvic. Infection is a rare cause for menorrhagia but requires urgent treatment of more than flow. A speculum exam will allow you to see the rare cervical or vaginal lesions that could also be a cause for heavy bleeding.
What medical ways can I treat menorrhagia?
Although the most commonly used first therapy for menorrhagia is a combined hormonal contraceptive (CHC) agent, the evidence that they are effective is slight. Randomized double blind placebo-controlled trial data shows no improvment and actual worsening of flow with combined hormonal contraceptives (CHC) over three months in perimenopausal women (10). Cyclic progestins have been used to treat menorrhagia but they have not been adequately tested in randomized controlled trials (11). However, a randomized trial of high-dose, long-cycle (cycle days 5-26) norethisterone (5 mg three times a day) showed that flow was reduced by 87% (12). Despite lack of multiple trials, based on what is known of the natural history of menorrhagia, and that full dose progesterone exposure (oral micronized progesterone [OMP] in a dose of 300 mg at bedtime) causes a decrease in estrogen levels (in premenopausal women) and counterbalances the effects of estradiol in everyone, progesterone or progestin therapy are appropriate for the outpatient treatment of menorrhagia.
Progesterone or progestin, to be effective for menorrhagia, must be given in large enough doses or long enough duration to counterbalance any increased estrogen effects. One common problem is that low menopausal ovarian hormone therapy (OHT) type progestin doses (such as 2.5 or 5.0 mg of medroxyprogesterone, MPA) are often tried. (MPA is stronger in control of flow than OMP).
The starting dose for menorrhagia treatment needs to be 300 mg of OMP at bedtime or 10 mg of medroxyprogesterone acetate (MPA). What is key is to give the OMP/MPA for a sufficiently long duration. OMP or MPA must be taken for at least 16 days per cycle (days 12-27) for premenopausal women and daily for three months in perimenopausal women. When you are aware that flow is heavy, no matter the cycle day, OMP/MPA should be started immediately.
For heavy flow in a woman who already has anemia or who is in Very Early Perimenopause with regular cycles or in the Early Menopause Transition Phase with irregular cycles plus typical perimenopause experiences such as night sweats, new sleep problems and increased premenstrual concerns, full dose oral micronized progesterone (OMP, 300 mg at bedtime) must be given daily for a full three months. (If OMP is too expensive then medroxyprogesterone acetate [MPA] can be given in a dose of 10 mg per day for three months.) Either OMP or MPA must also be given with ibuprofen (200-400 mg with each meal) on every heavy flow day.
For heavy flow in a teenager or the first episode in a premenopausal woman cyclic OMP or MPA (doses of 300 mg at bedtime or 10 mg respectively) over three to six cycles will usually be sufficient for heavy flow especially if given with ibuprofen (as described above).
The exception to the longer cycle cyclic OMP or MPA in premenopausal women, is if a woman is still premenopausal but gives a history of anovulatory androgen excess (PCOS) with acne and unwanted facial hair or says that heavy bleeding has been going on for "all her life" or for many months. Then, as in perimenopause, it is a good idea to start OMP/MPA therapy continuously rather than cyclically. In the case of perimenopause with PCOS, I usually treat with continuous full dose OMP/MPA (300 mg/10 mg) for three months. Following that, a cyclic treatment with OMP or MPA days 14 through 27 of the cycle for six more months is prudent. Give your patient the Cyclic Progesterone Therapy handout.
If your patient is perimenopausal, is over 40 or has ever had menorrhagia and will be in a remote area or traveling, I suggest supplying her with OMP/MPA in usual doses for 16 days, urge her to carry ibuprofen and to be prepared to initially treat herself for heavy flow.
What can I do for a menorrhagia emergency if other measures are insufficient?
Thankfully there are two further acute medical therapies for menorrhagia that have been shown to be both safe and effective in controlled trials and have been tested in randomized trials in comparison with hysterectomy or endometrial ablation. One therapy is the use of tranexamic acid which acts to increase the activity of the fibrin system (13) and the other is the levonorgestrel-releasing IUD, Mirena®. Although these combinations have not been scientifically evaluated, it makes sense to give either tranexamic acid or insert the LNG-IUD while continuing with standard heavy flow ibuprofen use and with a physiological dose cyclic progesterone therapy.
Tranexamic acid is used post operatively or for bleeding disorders. Because it is not commonly used, you should look up in a drug reference book. It is given in a dose based on the weight of the patient every four hours for two or three days of heavy flow. It has been shown to be superior to a non-steroidal agent such as ibuprofen (13) and to reduce flow by about 50% (14). I suggest continuing the progestin/progesterone therapy as above but add tranexamic acid if the flow remains or becomes very heavy despite it.
A levonorgestrel-releasing intrauterine device (LNG-IUD) for contraception and treatment of menorrhagia is now available in North American (after use in Finland and Europe for years). The higher dose of LNG-IUD is Mirena® that releases 20mg of levonorgestrel per day and reduces flow by 94% is needed for menorrhagia (12). A meta-analysis of randomized controlled trials of LNG-IUD compared with endometrial ablation showed similar reduction in blood flow and improved quality of life over the longer term without the risks of surgery (15). One 12-month study randomized 236 women (mean age 43, BMI 26, and menstrual blood loss of 129 ml/flow) to LNG-IUD or hysterectomy. Results showed similar improvement in quality of life using the SF-36 although pain was greater in the IUD group (16). Total and health care costs were triple for the hysterectomy group even though 20% of those randomized to LNG-IUD had hysterectomy during the year (16).
Disadvantages of surgical treatments for Menorrhagia
About 40-50% of North American women have had hysterectomy for benign reasons, allegedly for fibroids or menorrhagia (17). Besides the direct cost of hysterectomy, it requires at least six weeks of post-operative recovery and is sometimes associated with changes in a woman’s sexual response or a profound sense of loss. In perimenopause that is unchanged except for lack of flow following a hysterectomy, women often become disoriented and find the experiences even more difficult than usual to understand. At least two epidemiology studies have shown that perimenopausal women who have had a hysterectomy visit their health care providers more often than those who have not.
Endometrial ablation, which can be done by many different techniques, has been advocated as a less invasive and expensive surgery than hysterectomy. However, in a randomized comparative trial with follow-up over almost three years, 22% required a repeat operation (as the endometrium regrew). Although both groups were improved in health related quality of life, the pain dimension was more improved in those with hysterectomy and satisfaction with treatment was greater. Costs of endometrial ablation had increased to 71% of that of hysterectomy after a little over two years of follow-up (18) and, in another 4-yr study reached 93% of that of hysterectomy (19). Endometrial ablation is also commonly associated with unscheduled, irregular flow and spotting and in about 18-20% with pelvic pain.
Thus surgical therapies are rarely necessary for menorrhagia and should never be the first approach to treatment.
Wrapping it up
In summary, menorrhagia meaning blood loss of 80 ml or 16 soaked regular sanitary products or more per cycle occurs in 25% of Very Early Perimenopausal or early menopause transition women as well as in fewer adolescents and premenopausal women of any age. It is first treated with non-steroidal anti-inflammatory medications (ibuprofen 200-400 mg with each meal on every heavy flow day), fluid support and then with either cyclic full dose progesterone (OMP 300 mg at bedtime) or progestin (MPA 10 mg) for at least 14 days a cycle in premenopausal women or either OMP or MPA daily for three months in perimenopausal women. If further measures are needed, tranexamic acid or LNG-IUD can be used in addition to cyclic progesterone therapy and ibuprofen. Mirena® reduces blood flow by 94% and tranexamic acid by 50%. Most women prefer that these medical measures be optimally used before they want to consider surgical treatments such as hysterectomy or endometrial ablation.
It is important to assess and treat anemia and to maintain therapy for cramps. In early perimenopause heavy flow is sufficiently common that women in remote places or traveling should have a 16-day supply of OMP or MPA. Perimenopausal menorrhagia is very distressing to women, however its natural history is for it to resolve the closer a woman moves toward menopause (20).
Reference List
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