In a normal menstrual cycle, the
average woman loses a total of
30-40 ml of blood over three to
seven days. Heavy or prolonged
menstrual bleeding is known as
Research criteria defines this narrowly
as a monthly menstrual blood loss
in excess of 80 ml. A more practical
definition may be that of menstrual
loss that is greater than the woman
feels she can reasonably manage. The
National Institute for Health and Clinical
Excellence (NICE) in the UK defines
heavy menstrual loss as excessive blood
loss that interferes with a woman’s
physical, social, emotional and/or
quality of life.
Menorrhagia is a common problem in
clinical practice that can have adverse
effects on the quality of life for many
You may be experiencing menorrhagia
if you have the following:
Causes include :
1. Dysfunctional uterine bleeding
(excessive bleeding with no
identifiable cause): 20-40 percent.
2. Anovulatory cycles (more common
at extremes of reproductive age):
• This means that the ovaries
do not release the egg at each
cycle. This is due to hormonal
• In adolescents, the most
common cause is an immature
axis. (i.e. the chemical signalling
process between the brain and
• In perimenopausal women, it
can be due to the depletion of
3. Organic causes. Fibroids, endometrial
polyps, adenomyosis, endometritis,
pelvic inflammatory disease.
4. Endometrial hyperplasia and
carcinoma. This is a consideration
especially in patients above 40
years old or with risk factors such
as polycystic ovarian syndrome,
obesity, nulliparity, early menarche,
diabetes mellitus, excessive
oestrogen (female hormones)
either produced by the body or
5. Systemic disease. Including
hypothyroidism, liver or kidney
failure and bleeding disorders.
During consultation, your doctor will ask questions and perform an examination to try to determine the cause of the heavy menstrual bleeding.
Important information that you may provide to the doctor during the consultation include:
Clinical examination will be undertaken to assess for any anaemia and also to rule out potential organic causes of menorrhagia. This usually includes a pelvic examination.
Tests that may be carried out include:
A full blood picture will give an estimation of the degree of anaemia (low blood count). Other blood tests such as thyroid function tests and bleeding disorder testing may be performed if your doctor suspects a disorder.
The important conditions to rule out first include pregnancy, endometrial hyperplasia (abnormal thickening of the lining of the womb) and endometrial carcinoma.
If there are organic causes of menorrhagia, such as fibroids or adenomyosis, treatment options can be offered based on your wishes and fertility concerns.
If there is suspected chronic endometritis (risk factors include recent childbirth or intrauterine procedure), this can often be treated with a course of antibiotics.
If you are found to be anaemic, iron supplementation is usually recommended.
The general considerations guiding the choice of initial treatment are:
In the absence of any structural or
histological abnormalities, or fibroids
more than 3 cm causing distortion of
uterine cavity, the recommendations
for treatment are:
This may be considered also if you are close to menopause and other treatments are not working or contraindicated.
The choice of treatment will depend on both the uterine size and the patient’s desire to retain her uterus.