Menometrorrhagia

Key Points on Normal Menstruation

Menstruation is also commonly called menstrual period, menstrual bleeding, or monthly period.

• It is a normal monthly cycle that happens in females usually starting at ages 11-14. The first monthly period is called menarche. This is one of the signs of puberty.
• Menstruation is necessary to occur in a woman’s body because it prepares her for pregnancy. When a mature ovum is not fertilized by a sperm cell in one menstrual cycle, the endometrium or lining of the uterus sloughs off and the contents pass through the cervix and vagina.
• The hormones estrogen and progesterone regulate the menstrual cycle [1, 2].
• Menstruation lasts for 4 days. Prolonged bleeding for more than 7 days is termed menorrhagia.
• 28 days is the mean interval between menses. 21-35 days are still considered normal. Less than 21 days and more than 35 days interval are abnormal [3].
• Menstrual blood loss is approximately 30 mL although 10-80 mL is still considered normal [4].
• 36% of the menstrual discharge is composed of blood.
• 70% of the total blood loss occurs in the first two days of the menses.
• In each menses, you lose 13 mg of iron [3].

What is Menometrorrhagia

(Definition) : Menometrorrhagia [pronunciation: men’-o-me-tro-ra-je-a] is defined as heavy and prolonged bleeding occurring at irregular and frequent intervals [5]. It is having a menstrual haemorrhage at unpredictable times. Its ICD-9 code is 626.2 and ICD-10 code is N92.1.

Causes

Anovulation

Anovulatory cycle may be the reason for menometrorrhagia particularly for patients who are within two years after menarche. Estrogen makes the endometrium thick. The problem here is the lack of progesterone. Since ovulation does not happen, there is no progesterone that is responsible for the secretory phase of the cycle. As a result, the endometrium gets thicker and becomes unstable. This causes the prolonged, excessive bleeding [6].

Uterine Lesions

Lesions in the uterine cavity such as endometrial polyps may cause you to bleed out from the uterus.

Blood Coagulation Disorders

Menometrorrhagia may be caused by blood coagulation disorders such as prothrombin deficiency and von Willebrand’s disease, wherein there is a deficient clotting factor present in your blood [3]. Since there is a problem with coagulation, less clots will be formed, hence the prolonged bleeding.

If a patient has a personal or family history of bleeding tendencies or menstrual haemorrhage, check the prothrombin time (PT), activated partial thromboplastin time (APTT), and bleeding time [7]. In a study conducted by Claessens and Cowell, 20% of adolescent females suffered from abnormal uterine bleeding. Falcone, et. al. noted that 5% of these cases are caused by blood coagulation disorders.

Adenomyosis

“Adeno” means gland and “myo” refers to muscle. Adenomyosis is a condition wherein the glands of the uterus are lodged into the muscles. This leads to painful and heavy menstrual bleeding [8].
Endometrial Adenocarcinoma

Perimenopausal women who have intermenstrual and prolonged haemorrhage should be suspected of having carcinoma. Many believe that this is due to “unstable hormones” caused by aging that is why these cases often go unnoticed [7].
Hypothyroidism

Wilansky and Greisman’s conducted a study on 67 severely menorrhagic women with clinical normal thyroid function and levels. 15 of them had a positive response towards thyrotropin-releasing hormone (TRH) stimulation test. A daily dose of 50-200 mg levothyroxine was given to these women for 3-6 months and the heavy and prolonged bleeding was treated [3].
Cirrhosis

Cirrhosis will make the liver inefficient in metabolizing the estrogen. This may subsequently lead to menometrorrhagia.
Diagnosis

• Endometrial Biopsy or Curettage: Results will show fluctuating estrogen levels [9].
• Papanicolaou (PAP) Smear: A standard procedure to microscopically check for cervical cancer.
• Endovaginal Ultrasound: To visualize intrauterine lesions.
• Hysteroscopy: This is the gold standard in directly visualizing the uterus to look for any kinds of abnormalities and collect tissue samples. This is also used as a form of treatment modality because gross abnormalities can be corrected on the spot while performing the procedure.
• Saline Infusion Ultrasonography: This is the less invasive version of hysteroscopy wherein 10-15 mL of saline is infused to visualize endometrial lesions. However, unlike in hysteroscopy, tissue samples cannot be collected and “see-and-treat” cannot be done using this procedure.
• Prothrombin Time, Activated Partial Thromboplastin Time, and Bleeding Time: To determine if the cause of menometrorrhagia is a disorder of blood coagulation [7].

Differential Diagnosis

Menometrorrhagia is often confused with other forms of abnormal endometrial bleeding. What makes them different with menometrorrhagia?

Menorrhagia

Menorrhagia, also known as hypermenorrhea, is defined as a regular menstruation with prolonged or heavy flow. The menstrual blood loss is 80 mL or more OR the patient may have a period that may last for more than 8 days.

Metrorrhagia

Metrorrhagia is defined as an irregular menstruation with both prolonged and heavy flow. The menstrual blood loss is 80 mL or more AND the duration of the monthly period lasts for more than 8 days [10].

Natural Treatment

• Banana Flower: It helps in decreasing menstrual blood flow by increasing progesterone levels. Cook and eat it with a curd.
• Agrimony: It reduces menstrual flow and it alleviates the cramping. It has a soothing and aromatic taste of an herbal tea.
• Mustard Seeds: Grind 50 grams of dried mustard seeds. Drink this dissolved in a goat’s milk twice a day 2-4 days before your menstruation cycle starts.
• Coriander Seeds: Boil 20 grams of this in a cup of water. Remove from heat then drink when only one-fourth of the decoction remains.
• Mango Bark: Take one teaspoon of a mixture of 10 mL of mango bark extract and 120 mL of water every hour [11, 12].

Medical Management

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

In menometrorrhagic uterus, thromboxane inhibitors called prostacyclins are produced in large amounts. Thromboxanes function as platelet aggregators and blood coagulators. These are inhibited in menometrorrhagia because of the presence of prostacyclins. NSAIDs such as naproxen and diclofenac prevent further formation of prostacyclins thereby promoting the function of thromboxanes and decreasing menstrual blood flow [13].

High Dose Conjugated Equine Estrogen

Estrogen is responsible for the thickening of the endometrium during menstrual cycles. Patients who do not have enough estrogen may have an irregular period since the endometrium is not given time to be thick enough for it to slough off. Estrogen helps to stabilize the bleeding. Furthermore, it increases clotting factors V and IX and fibrinogen thereby allowing the platelets to aggregate and form clots. With this, bleeding decreases [14].

Selective Progesterone Receptor Modulators (SPRM)

SPRM’s target is the blood vessels of the uterus. Studies have proven this effective in decreasing menstrual blood flow without affecting angiogenic factors and extracellular matrix composition [15].

Danazol (Danocrine)

Danazol is a form of androgen (synthetic steroid analog) that inhibits luteinizing and follicle-stimulating hormones. As a result, endometrium atrophies. It also enhances erythropoiesis and thrombopoiesis.
Arginine Vasopressin Derivatives

This is the option for patients who have menometrorrhagia caused by blood coagulation disorders. It increases factor VIII and von Willebrand factor [13].

Blood Transfusion

For patients who suffer from anemia due to excessive bleeding, blood transfusion is necessary.

Iron and Folic Acid Supplements

Normally, 13 mg of iron are lost during a menstrual period [3]. Since there is an excessive blood loss in menometrorrhagia, far more than 13 mg of iron are lost for sure. Iron and folic acid supplements correct the anemia.

Ibuprofen and Acetaminophen

Take these for pain management.

Surgical Intervention

Hysterectomy

This is the definitive treatment for menometrorrhagia since the problem itself, the uterus, is being removed permanently [14]. However, this may be an issue if the couple wants to have their own offsprings. In this case, other options must be presented.

Endometrial Ablation

This is a procedure to remove the endometrium or the lining of the uterus. Endometrium is the one that is being sloughed off during menstruation. Since ablation is done to it, bleeding is reduced [16].

Dilatation and Curettage (D&C)

D&C is a temporary treatment for menometrorrhagia so this may not be the best option for this condition. Its usefulness may only serve you for 1-2 months.

Complications

Iron Deficiency Anemia

Too much blood is lost in menometrorrhagia. Consequently, there will be low levels of haemoglobin that transport oxygen to body tissues and this leads to pallor, dizziness, and fatigue.

Dysmenorrhea

Menometrorrhagia carries endometrial cramping with it. NSAIDs may do the job of alleviating it.

Infertility

The irregularity in menstruation and hormonal imbalances may be factors for a woman to become infertile [17].

References:

1. Normal Menstrual Cycle – Topic Overview accessed on http://www.webmd.com/women/tc/normal-menstrual-cycle-topic-overview
2. Menstruation: Learn All About the Cycle accessed on http://www.medicinenet.com/menstruation/article.htm
3. Katz VL, et al., Comprehensive Gynecology 5th edition, Mosby 2007
4. Abnormal Uterine Bleeding: Pathophysiology and Clinical Management accessed on http://www.medicine.uic.edu/UserFiles/Servers/Server_442934/File/OBGYN%20Med%20Ed/STUDENTS/Lectures/ELAM%20-%20AUB%20talk.pdf
5. Definition of Menometrorrhagia accessed on http://www.medterms.com/script/main/art.asp?articlekey=4351
6. Golub S, Health Care of the Female Adolescent, Routledge 2014
7. Hall JE & Nieman LK, Handbook of Diagnostic Endocrinology, Humana Press Inc. 2003, p 314
8. Menorrhagia accessed on http://www.mayoclinic.org/diseases-conditions/menorrhagia/basics/causes/con-20021959
9. Becker KL, Principles and Practice of Endocrinology and Metabolism, Lippincott Williams & Wilkins 2001, p 1014
10. Ostrzenski A, Gynecology: Integrating Conventional, Complementary, and Natural Alternative Therapy, Lippincott Williams & Wilkins 2002, p 104
11. Priyo News: Menorrhagia Treatment with Herbal accessed on http://news.priyo.com/health/2011/05/19/menorrhagia-treatment-herbal-26459.html
12. 10 Best Natural Remedies for Menorrhagia accessed on http://www.bhtips.com/2011/12/10-best-natural-home-remedies-for.html
13. Menorrhagia Medication accessed on http://emedicine.medscape.com/article/255540-medication#2
14. Inpatients With Menometrorrhagia: Etiologies, Treatments, and Outcomes accessed on http://www.medscape.com/viewarticle/410561_4
15. Current and future medical treatments for menometrorrhagia during the premenopause accessed on http://informahealthcare.com/doi/abs/10.3109/09513590.2012.638754
16. Heavy Menstrual Bleeding accessed on http://www.bostonscientific.com/en-US/health-conditions/heavy-menstrual-bleeding.html
17. Menorrhagia – Excessive Menstrual Bleeding accessed on http://www.women-md.com/Welcome/PatientEducationLibrary/tabid/14200/ctl/View/mid/24325/Default.aspx?ContentPubID=453