Etica

Clinical review
Fortnightly review
Medical management of menorrhagia
Andrew Prentice
Introduction
Excessive menstrual loss, or menorrhagia, is a
significant healthcare problem in the developed world
(box 1). In the United Kingdom, 5% of women of
reproductive age will seek help for this symptom annu­
ally1; by the end of reproductive life the risk of hyster­
ectomy (primarily formenstrual disorders) is 20%.2
This is also the situation in New Zealand.3 Objectively,
menorrhagia is defined as a menstrual loss of 80 ml
per month. Population studies have shown that this
amount of loss is present in 10% of the population4 yet
nearly a third of all women consider their menstrua­
tion to be excessive.5 This symptom thus creates a sig­
nificant workload for health services.
Inclinical medicine the paradigm of evidence
based medicine currently holds sway. Evidence based
medicine implies not only the application of effective
treatments but their rational use within a rational over­
all management framework. In the management of
excessive menstrual loss there is good evidence that
many doctors do not necessarily prescribe the most
effective treatments. In the UnitedKingdom, for exam­
ple, more than a third of general practitioners
prescribe norethisterone—arguably the least effective
option—as first line treatment, whereas only 1 in 20
prescribe tranexamic acid—probably the most effective
first line treatment.6 The problem is not confined to
primary care. In New Zealand, where the use of
tranexamic acid is restricted to secondary care, 50% ofgynaecologists still use luteal phase progestogens, and
less than 10% use tranexamic acid.7
Methods
This review attempts to provide a rational overview of
the diagnostic and therapeutic management of menor­
rhagia, relying on the systematic reviews presented in
three papers—two guidelines for the management of
excessive menstrual loss published in 19988 9 and a
consensus view published in199510—and the
Cochrane library for the source literature.
Cause and pathology of menorrhagia
Menorrhagia can be associated with both ovulatory and
anovulatory ovarian cycles. It is important to distinguish
the menstrual consequences of each cycle. Ovulatory
ovarian cycles give rise to regular menstrual cycles
whereas anovulatory cycles result in irregular menstrua­
tion or, extremely, amenorrhoea.This distinction is criti­
cal in management. Both ovulatory and anovulatory
cycles can give rise to excessive menstrual loss in the
absence of any other abnormality; so called dysfunc­
tional uterine bleeding. Other disorders may be
associated with excessive loss, for example, fibroids and
adenomyosis, but the association may not always be
causal. Endocrine disorders do not causeexcessive men­
strual loss, with the exception of the endocrine
consequences of anovulation. Equally, except in selected
populations, haemostatic disorders are rare causes of
menorrhagia despite suggestions to the contrary.11
Excessive menstrual loss in regular menstrual cycles
is the most common clinical presentation. Such patients
ovulate regularly. Laboratory based research has shown
thatseveral abnormalities can occur in the
endometrium of women with this problem—for
example, increased fibrinolytic activity12 and increased
production of prostaglandins.13 These observations pro­
vide the rational basis for treatment in these women.
Box 1: Indications for referral to a
gynaecologist or for surgical management
Age over 40
Persistent intermenstrual bleeding
Failed medicaltreatment
Other factors—for example, abnormal smear,
associated severe dysmenorrhoea
Summary points
Menorrhagia is an important healthcare issue
Despite widely available evidence inappropriate
treatments are being prescribed
Guidelines exist for the appropriate management
of menorrhagia
Appropriate treatments enhance patient choice
and may increase patient satisfaction
Medical...