What are the causes of prolonged menstrual bleeding, also known as menorrhagia (Heavy Menstrual Bleeding)?

From the Guidelines

Prolonged menstrual bleeding is most commonly caused by hormonal imbalances, uterine fibroids, or other underlying gynecological problems, and the most effective treatment approach should prioritize addressing the underlying cause while considering the patient's overall health and quality of life. When evaluating the cause of prolonged menstrual bleeding, it is essential to consider various factors, including hormonal fluctuations, structural abnormalities of the uterus, and medical conditions such as polycystic ovary syndrome (PCOS) 1. The treatment options for prolonged menstrual bleeding can vary depending on the underlying cause, but may include hormonal medications like birth control pills, tranexamic acid to promote blood clotting, or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen to reduce bleeding 1. In cases where the bleeding is associated with uterine fibroids, medical management options such as NSAIDs, estrogen-progestin oral contraceptive pills, or tranexamic acid may be considered, with the goal of reducing bleeding symptoms and improving quality of life 1. The most recent and highest quality study recommends considering an underlying gynecological problem, such as interactions with other medications, an STD, pregnancy, or new pathologic uterine conditions, and treating the condition or referring for care if necessary 1. Key considerations in managing prolonged menstrual bleeding include:

• Identifying and addressing the underlying cause of the bleeding
• Evaluating the patient's overall health and medical history
• Considering the potential benefits and risks of different treatment options
• Prioritizing the patient's quality of life and well-being in the treatment approach. It is crucial to consult a healthcare provider for proper diagnosis and treatment, especially if the bleeding is accompanied by severe pain, extreme fatigue, or very heavy flow 1.

From the Research

Causes of Prolonged Menstrual Bleeding

• Uterine pathologies, such as fibroids and endometrial polyps, are common causes of heavy menstrual bleeding, with fibroids being more common in women under 40 years of age and endometrial polyps being more common in women over 40 years of age 2
• Coagulopathy, ovulation dysfunction, and iatrogenic factors can also contribute to heavy menstrual bleeding 3
• Uterine fibroids (UFs) are the most common female benign pelvic tumors, affecting over 60% of patients aged 30-44 years, and can cause abnormal uterine bleeding and heavy menstrual bleeding 4

Diagnosis and Assessment

• A menstrual and gynaecological history and a bleeding score can help distinguish women who require additional haematological investigations 3
• A pelvic examination and ultrasound scan can help rule out underlying pathology 3
• Vaginal sonography combined with an endometrial biopsy is a reliable method for diagnosing endometrial hyperplasia or carcinoma, but is insufficient for diagnosing endometrial polyps and fibroids 2

Management and Treatment

• Medical therapies, such as hormonal treatments, levonorgestrel-releasing intrauterine system (LNG-IUS), and combined hormonal contraceptives, can be effective in reducing menstrual blood loss 2, 3, 5
• Tranexamic acid and non-steroidal anti-inflammatory drugs can also reduce menstrual blood loss 2, 3, 6
• Surgical options, such as hysterectomy and myomectomy, may be considered for women who do not respond to medical treatment or who wish to preserve their fertility 4, 6