Causes of Menorrhagia in a 35-Year-Old Woman with Prior Healthy Pregnancies
In a 35-year-old woman with previous healthy pregnancies presenting with menorrhagia, the most common causes are uterine fibroids (leiomyomas), endometrial polyps, adenomyosis, and underlying bleeding disorders—particularly von Willebrand disease, which affects up to 20% of women with heavy menstrual bleeding. 1
Structural Uterine Pathology
Uterine fibroids are the leading structural cause in women under 40 years of age, while endometrial polyps become more prevalent after age 40. 2 In approximately 50% of menorrhagia cases, however, no structural pathology is identified at hysterectomy, suggesting functional or hemostatic abnormalities. 3
- Submucosal fibroids are particularly associated with heavy menstrual bleeding and can be identified through transvaginal ultrasound or saline infusion sonohysterography. 4, 5
- Endometrial polyps may not be reliably diagnosed by vaginal sonography alone and require sonohysterography or hysteroscopy for accurate detection. 2
- Adenomyosis should be considered, especially if the patient has dysmenorrhea accompanying the heavy bleeding. 5
Hemostatic and Coagulation Disorders
Von Willebrand disease is the most common inherited bleeding disorder causing menorrhagia, affecting a significant proportion of women with heavy menstrual bleeding. 1, 5
- A bleeding assessment tool (BAT) should be used to identify women requiring hematological investigation—the ISTH BAT is most commonly utilized. 4
- Women with a positive bleeding history (easy bruising, prolonged bleeding after dental procedures, postpartum hemorrhage) warrant coagulation studies including von Willebrand factor testing. 1
- Routine coagulation screening of all women with menorrhagia is unnecessary unless the bleeding history suggests an underlying disorder. 6
Endocrine and Ovulatory Dysfunction
While less likely in a woman with prior healthy pregnancies, thyroid dysfunction, hyperprolactinemia, and polycystic ovary syndrome can cause abnormal bleeding patterns. 5
- Anovulatory bleeding typically presents as irregular rather than cyclical heavy bleeding, making it less consistent with classic menorrhagia. 5
- Thyroid function testing should be performed as thyroid dysfunction can cause both anovulatory and ovulatory bleeding patterns. 5
Endometrial Pathology
Endometrial hyperplasia and carcinoma must be excluded, particularly given risk factors. 5
- Women 35 years or older with recurrent anovulation or risk factors for endometrial cancer require endometrial biopsy. 5
- Transvaginal ultrasound combined with endometrial biopsy is reliable for diagnosing endometrial hyperplasia or carcinoma. 2
Functional Causes
In the absence of structural or systemic pathology, abnormal levels of prostaglandins or dysregulation of the fibrinolytic system in the endometrium have been implicated in menorrhagia. 3
Critical Diagnostic Approach
Pelvic examination and transvaginal ultrasound are essential first-line investigations. 2 If the ultrasound shows intracavitary abnormalities or if initial evaluation is inconclusive, saline infusion sonohysterography is less expensive and invasive than hysteroscopy while effectively detecting endometrial polyps and submucosal fibroids. 5, 2
Common Pitfall
The patient's subjective assessment of menstrual blood loss does not reliably reflect actual volume—objective measures or impact on quality of life and anemia are more clinically relevant. 2 Focus on whether the bleeding interferes with physical, emotional, and social wellbeing rather than attempting to quantify exact blood loss. 1