prolonged mensuration
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menorrhagia heavy menstrual bleeding management
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Prolonged Menstruation (Heavy Menstrual Bleeding / Menorrhagia)
Definition
Per the FIGO (International Federation of Gynecology and Obstetrics) classification, the preferred modern term is Abnormal Uterine Bleeding (AUB):
| FIGO Term | Definition |
|---|---|
| Prolonged menstrual bleeding | Menstrual periods exceeding 8 days' duration on a regular basis |
| Heavy menstrual bleeding (HMB) | Excessive bleeding interfering with physical, emotional, social, or quality of life — defined by the patient's perception, regardless of exact volume |
| Abnormal uterine bleeding (AUB) | Bleeding irregular in regularity, volume, frequency, or duration; present for ≥6 months |
Older terms like menorrhagia, metrorrhagia, and dysfunctional uterine bleeding have been discarded by FIGO. Normal menstrual blood loss is ≤30 mL; >80 mL is considered abnormal. — Tintinalli's Emergency Medicine
PALM-COEIN Classification of Causes
FIGO uses the PALM-COEIN system to categorize causes of AUB:
PALM — Structural Causes
| Cause | Notes |
|---|---|
| Polyps | Endometrial/endocervical; often cause intermenstrual or prolonged bleeding; diagnosed on US or hysteroscopy |
| Adenomyosis | Endometrial glands within the myometrium; heavy/prolonged periods in 4th–5th decade; MRI is gold-standard imaging |
| Leiomyoma (fibroids) | Most common benign pelvic tumor; 25% of white women, 50% of Black women affected; submucosal fibroids most often cause bleeding |
| Malignancy / hyperplasia | Endometrial hyperplasia (excess unopposed estrogen → precursor to carcinoma); postmenopausal bleeding is a red flag |
COEIN — Non-Structural Causes
| Cause | Notes |
|---|---|
| Coagulopathy | Von Willebrand disease most common; up to 20% of women with HMB have an underlying coagulation disorder; also ITP, platelet disorders |
| Ovulatory dysfunction | Most common overall cause — anovulation; most frequent at menarche and perimenopause due to immature/failing HPO axis |
| Endometrial | Endometritis, primary endometrial disorders |
| Iatrogenic | Oral contraceptives, anticoagulants, SSRIs, tamoxifen, IUDs, herbal supplements (e.g., ginseng) |
| Not yet classified | — |
— Robbins & Kumar Basic Pathology; Goldman-Cecil Medicine; Tintinalli's Emergency Medicine
Causes by Age Group
| Age | Primary Causes |
|---|---|
| Prepuberty | Precocious puberty (hypothalamic/pituitary/ovarian origin) |
| Adolescence | Anovulatory cycles, coagulation disorders (up to 24% of adolescents with HMB may have a bleeding disorder) |
| Reproductive age | Pregnancy complications (miscarriage, ectopic, trophoblastic disease), anatomic lesions (fibroids, polyps, adenomyosis, hyperplasia, carcinoma), anovulation/PCOS, coagulopathy |
| Perimenopausal | Anovulation due to declining ovarian function; structural lesions |
| Postmenopausal | Endometrial carcinoma must be excluded |
Pathophysiology of Anovulatory Bleeding (Most Common)
In anovulation, estrogen stimulates the endometrium unopposed by progesterone. The endometrium proliferates, becomes thicker, and sheds irregularly — producing prolonged or heavy bleeding. Anovulatory bleeding tends to occur at less frequent intervals, while organic lesions tend to cause more frequent bleeding.
Common causes of anovulation:
- Hypothalamic-pituitary-ovarian axis immaturity (menarche) or failure (perimenopause)
- PCOS
- Prolactin-secreting pituitary tumors (suppress GnRH → ↓LH/FSH)
- Granulosa cell tumors of the ovary
- Obesity, malnutrition, chronic systemic illness
- Thyroid disorders, diabetes mellitus, Cushing syndrome
Diagnosis
History:
- Bleeding pattern (duration, volume, interval, clots)
- Family history of bleeding disorders
- Medications (anticoagulants, OCP, SSRIs)
- Pregnancy history
Screening questions for coagulopathy: Heavy bleeding since menarche, postpartum hemorrhage, surgical/dental bleeding + ≥2 of: bruising 1–2×/month, epistaxis 1–2×/month, frequent gum bleeding, family history
Physical examination:
- Hemodynamic stability first
- Signs of anemia (pallor, tachycardia)
- Hirsutism/obesity/galactorrhea → endocrinologic cause
- Petechiae/purpura/mucosal bleeding → hematologic cause
- Pelvic exam: speculum + bimanual for masses, tenderness
Laboratory workup:
- Complete blood count + platelets
- Coagulation studies (including von Willebrand panel)
- Thyroid function tests
- Fasting blood glucose
- Pregnancy test (always)
- Pap smear
Imaging:
- Pelvic ultrasound (first-line for structural causes)
- Sonohysterography or hysteroscopy for intracavitary lesions
- MRI for adenomyosis
Endometrial sampling:
- Required for all women >35 years and any patient at increased risk for endometrial carcinoma (prolonged anovulatory bleeding, obesity, tamoxifen use)
— Goldman-Cecil Medicine; Tintinalli's Emergency Medicine
Management
Medical (First-line)
| Treatment | Indication/Notes |
|---|---|
| Combined OCP | Anovulatory bleeding — 1 pill q6h × 5–7 days stops acute bleeding within 24 hours; warn of heavy withdrawal bleed 2–4 days after stopping |
| Progestin | Anovulatory/PCOS-related bleeding; oral or injectable |
| Levonorgestrel IUD (Mirena) | Highly effective for heavy menstrual bleeding and dysmenorrhea; also useful in PCOS and fibroids |
| NSAIDs | Ovulatory AUB; reduce blood loss by ~20–30% |
| Tranexamic acid | Antifibrinolytic; effective for acute heavy bleeding |
| GnRH agonists | Preoperative reduction of fibroid size; not long-term |
Procedural/Surgical
| Procedure | Indication |
|---|---|
| Endometrial ablation | Alternative to hysterectomy; ~29% require hysterectomy by 5 years |
| Uterine artery embolization | Symptomatic fibroids; ~31% ultimately undergo hysterectomy |
| Myomectomy | Fertility-preserving removal of fibroids |
| Polypectomy / D&C | Polyp removal; D&C alone is not effective for controlling bleeding long-term |
| Hysterectomy | Reserved for failure of medical therapy; definitive cure |
Hysterectomy should be reserved for patients who do not respond to or cannot tolerate medical therapy. Alternatives (ablation, UAE) should be considered first. Endometrial sampling must be performed before hysterectomy. — Berek & Novak's Gynecology
Red Flags Requiring Urgent Evaluation
- Postmenopausal bleeding (→ rule out endometrial carcinoma)
- Hemodynamic instability
- Suspected pregnancy complication (ectopic, molar)
- Bleeding with coagulopathy signs
Recent Evidence
A 2025 systematic review and meta-analysis (PMID: 39617186) provides updated data on the etiology and diagnosis of heavy menstrual bleeding across adolescent and adult populations, confirming high rates of coagulation disorders in adolescents with HMB.
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