Menorrhagia
Definition
Excessive menstrual blood loss interfering with physical, emotional, social and material quality of life
Can result in symptomatic anaemia and significantly affect daily activities
Causes and Differential Diagnoses
Anovulatory cycles are the most common cause in adolescents and young women
Structural causes such as fibroids, polyps, adenomyosis or malignancy
Endocrine disorders including thyroid dysfunction and polycystic ovarian syndrome
Coagulopathies such as von Willebrand disease and other bleeding disorders
Iatrogenic causes including effects of certain medications
Assessment and Investigations
Detailed menstrual history including duration, frequency, volume of bleeding and its impact on daily life
Physical examination with pelvic assessment for uterine size, tenderness and masses
Laboratory tests: full blood count, serum ferritin, thyroid function tests, coagulation screen and pregnancy test
Imaging: pelvic ultrasound to evaluate uterine pathology when indicated
Consider endometrial sampling in patients with risk factors for endometrial pathology
General Management Principles
Tailor management to severity, underlying cause, patient’s age, fertility desires and risk factors
Aim to reduce menstrual blood loss, improve haemoglobin levels and enhance quality of life
Involve shared decision making through comprehensive patient education and use of a menstrual calendar
First-Line Treatment
Second-Line Treatments
Tranexamic acid: 1 g PO three to four times daily during the first 3–5 days of menstruation
Nonsteroidal anti-inflammatory drugs (NSAIDs):
Combined oral contraceptive pill: Ethinylestradiol 35 mcg with levonorgestrel 150 mcg in an extended (3-month) or continuous regimen
Additional Pharmacological Options
Progestogens:
Medroxyprogesterone acetate (MPA): 10 mg PO one to three times daily from day 1 to 21 of a 28-day cycle, for up to 6 months
Norethisterone: 5 mg PO two to three times daily from day 1 to 21 of a 28-day cycle, for up to 6 months
Management of Anovulatory Menorrhagia
Non-Pharmacological Management
Lifestyle modifications including achieving an ideal body weight and smoking cessation
Regular use of NSAIDs during menses may reduce blood loss and alleviate associated pain
Patient education regarding dietary modifications and tracking menstrual patterns
Referral Criteria
Refer to gynaecology if symptoms persist for more than 6 months despite treatment
Severe dysmenorrhoea affecting quality of life
Presence of fibroids larger than 3 cm
Increased risk of endometrial cancer such as in cases of PCOS or oligomenorrhoea
Specialist interventions may include uterine artery embolisation, myomectomy, hysteroscopic fibroid resection or hysterectomy
Early referral ensures timely intervention and management of underlying pathology
Additional High-Yield Points
Menorrhagia can have a profound impact on quality of life and requires assessment of its effect on daily activities
Evaluation for bleeding disorders is particularly important in adolescents and young women
Regular monitoring of haemoglobin and iron status is critical, with consideration for iron supplementation
The LNG-IUD is highly effective yet underutilised; increased awareness and training may improve uptake
Combined treatment approaches, integrating pharmacological and non-pharmacological strategies, often yield the best outcomes
Shared decision making and informed choice are essential components of management to align treatment with patient preferences
