Menorrhagia (excessive bleeding) is most commonly caused by anovulatory menstrual cycles. Occasionally it is caused by thyroid dysfunction, infections or cancer. Menorrhagia caused by anovulation is referred to as dysfunctional uterine bleeding.
Pathophysiology of normal menstruation
In response to gonadotropin-releasing hormone from the hypothalamus, the pituitary gland synthesizes follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which induce the ovaries to produce estrogen and progesterone.
During the follicular phase, estrogen stimulation causes an increase in endometrial thickness. After ovulation, progesterone causes endometrial maturation and secretory changes. Menstruation is caused by estrogen and progesterone withdrawal.
Abnormal bleeding is defined as bleeding that occurs at intervals of less than 21 days, more than 36 days, lasting longer than 7 days, or blood loss greater than 80 mL.
Clinical evaluation of abnormal vaginal bleeding
A menstrual and reproductive history is obtained, including last menstrual period, regularity, duration, and frequency; the number of pads used per day and the presence of intermenstrual bleeding should be assessed.
Stress, exercise, weight changes and systemic diseases, particularly thyroid, renal or hepatic diseases, or coagulopathies should be sought. The method of birth control should be determined.
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Pregnancy complications, such as spontaneous abortion, ectopic pregnancy, placenta previa and abruptio placentae, can cause non-cyclical, heavy bleeding. Pregnancy should always be considered as a possible cause of abnormal vaginal bleeding.
Determine whether the patient is having ovulatory or anovulatory cycles
Ovulatory cycles are characterized by menstrual flows occurring at regular intervals, preceded by premenstrual symptoms (breast tenderness or fullness, pelvic cramping, and edema).
If cycles are anovulatory, the patient has dysfunctional uterine bleeding.
Puberty and adolescence–menarche to age 16
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Irregularity is normal during the first few months of menstruation; however, soaking more than 25 pads or 30 tampons during a menstrual period is abnormal.
Absence of premenstrual symptoms (breast tenderness, bloating, cramping) is associated with anovulatory cycles.
Fever, particularly in association with pelvic or abdominal pain may, indicate pelvic inflammatory disease. A history of easy bruising suggests a coagulation defect. Headaches and visual changes suggest a pituitary tumor.
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