Skip to Main Content

Menorrhagia (Heavy Menstrual Bleeding)

Heavy menstrual bleeding (HMB) is the most common presentation of abnormal uterine bleeding in premenopausal women. Excessive menstrual blood loss is defined as that which interferes with the woman’s quality of life. Abnormal uterine bleeding is classified using nine categories, separated into structural and non-structural conditions (PALM-COEIN):

  • Polyp, Adenomyosis, Leiomyoma, Malignancy

  • Coagulopathy, Ovulatory disorders, Endometrium, Iatrogenic and Not otherwise specified

Table M4Menorrhagia: diagnostic strategy model
View Table||Download (.pdf)
Table M4 Menorrhagia: diagnostic strategy model

Probability diagnosis

Ovulatory dysfunction

Fibroids

Cervical or endometrial polyps

Complications of hormone therapy

Serious disorders not to be missed

Disorders of pregnancy

  • ectopic pregnancy

  • abortion or miscarriage

Neoplasia/cancer

  • cervical cancer

  • endometrial cancer

  • oestrogen-producing ovarian tumour (cancer)

  • leukaemia

  • benign tumours (polyps, etc.)

Endometrial hyperplasia

Infection

  • PID

  • tuberculous endometritis

Pitfalls (often missed)

Genital tract trauma

Copper IUD

Adenomyosis/endometriosis

SLE

Bleeding disorders

Medical management

  • Offer oral treatment while waiting for investigations, e.g. tranexamic acid. The most effective medical treatment is the levonorgestral 52 mg IUD (Mirena). Other options are listed in Table M5.

|Download (.pdf)|Print
Table M5 Regimens used in the management of heavy menstrual bleeding

Therapy

Mean reduction in mean blood loss 80 mL/cycle %

Levonorgestrel (IUCD) Mirena 52 mg—replace every 5 yrs

94

Oral progestogen:

83

  • norethisterone 5 mg (o) tds on d 5–26 of cycle

Tranexamic acid:

  • 1 g (o) 6 hrly on d 1–4 of menstruation

47

Combined oral contraceptive pill

43

NSAIDs (oral):

  • ibuprofen 400 mg 3 or 4 times daily or

  • naproxen 500 mg statim then 250 mg every 6–8 hrs or

  • mefenamic acid 500 mg tds

29

Surgical management

Options include:

  • myomectomy, polypectomy

  • uterine artery emolisation

  • endometrial ablation

  • hysterectomy

Drug therapy regimens See Tables M5 and M6.

|Download (.pdf)|Print
Table M6 Treatment options for acute and severe heavy bleeding

Practice tip

Acute severe uterine bleeding (treat until bleeding stops):

  • tranexamic acid 1–1.5 g (o) 6–8 hrly or

  • noresthisterone 5–10 mg (o) 4 hrly or

  • medroxyprogesterone 10 mg (o) 4–8 hrly or

  • ethinyloestradiol 30–35 mcg combined oral contraceptive pill, 6 hrly, re-evaluate after 48 hrs

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MH Privacy Center Close