INTRODUCTION

In a normal menstrual cycle, the average woman loses about 2 to 3 tablespoons (35 to 40 milliliters) of blood over three to seven days. However, some women lose a lot more blood. Menorrhagia is the medical term for heavy or prolonged menstrual bleeding. Most women have a menstrual period every 25 to 35 days; the average is every 28 days.

Women who lose 5 to 6 tablespoons (about 80 milliliters) of blood or more during their menstrual period are said to have menorrhagia. Losing a lot of blood during the menstrual period can cause medical problems like anemia (low number of red blood cells).

There are several treatments for heavy bleeding. More detailed information about heavy menstrual bleeding is available by subscription. (See "Chronic menorrhagia or anovulatory uterine bleeding".)

MENORRHAGIA CAUSES

The most common causes of excessive menstrual bleeding are:

• Not ovulating once per month (called anovulation)
• Having abnormal growths in the uterus, such as polyps or fibroids
• Having a condition that increases bleeding throughout the body

Anovulation — Anovulation occurs when your ovaries do not produce and release an egg (ovulate) once per month. This causes your menstrual period to be irregular or absent. Anovulation is common in adolescents and in women who are near menopause. Women with polycystic ovary syndrome (PCOS) often do not ovulate regularly. (See "Patient information: Menstrual cycle disorders (absent and irregular periods)".)

Growths in the uterus — Noncancerous growths in the uterus can cause heavy menstrual bleeding. The most common noncancerous growths are:

• Polyps, which are small, grape-like growths of the lining of the uterus
• Fibroids (see "Patient information: Uterine fibroids")
• Overgrowth of the lining of the uterus (called endometrial hyperplasia, which can be a precursor to uterine cancer)

Bleeding tendency — Women with certain bleeding conditions or who take certain medicines can have heavy menstrual bleeding. Examples include:

• von Willebrand disease (see "Patient information: von Willebrand disease")
• Having a low platelet count
• Taking a blood thinner like warfarin (see "Patient information: Warfarin (Coumadin®)")

MENORRHAGIA SYMPTOMS

Women with menorrhagia typically have one or more of the following:

• Need to change pads or tampons more than every three hours or use more than 21 pads or tampons during a period
• Need to use both pads and tampons at the same time due to heavy bleeding
• Need to change pads or tampons during the night
• Pass blood clots larger than 1 inch
• Iron deficiency anemia (see "Patient information: Iron deficiency anemia")

When to seek help — If you soak through two pads or tampons in one hour for two hours in a row, call your doctor or nurse or go to the emergency department. Bleeding this heavily can be serious or even life threatening.

MENORRHAGIA DIAGNOSIS

If you have heavy menstrual bleeding, your doctor or nurse will want to perform a physical exam, including a pelvic exam. The doctor or nurse might recommend other tests, based on what he or she finds during the exam. This can include:

• A biopsy of the tissue inside of the uterus, called an endometrial biopsy. This can be done in the office.
• A hysteroscopy, which uses a small telescope to look inside the uterus
• Blood tests to look for a bleeding disorder, anemia, or thyroid disease
• A pelvic ultrasound uses sound waves to create a picture of the uterus and ovaries. An ultrasound can detect endometrial polyps and fibroids.

MEDICAL TREATMENT FOR MENORRHAGIA

The best treatment of heavy menstrual bleeding depends on:

• The cause of your bleeding
• Your preferences
• The need to prevent pregnancy
• Your desire to have children in the future

Your doctor or nurse will probably recommend treatment with one or more medicines first. If these treatments do not reduce bleeding enough, a surgical treatment might be an option (see 'Surgery for menorrhagia' below).

Hormonal birth control — Hormonal methods of birth control include the pill, skin patch, vaginal ring, shot, hormonal IUD, and implant. These treatments reduce bleeding during your menstrual period. Hormonal birth control can also reduce cramps and pain during your period. It might take three months for bleeding to improve after you start taking hormonal birth control.

Most forms of hormonal birth control, including the pill, skin patch, and vaginal ring, are designed to be used for three weeks in a row, followed by one week off. During the fourth week, you will have menstrual bleeding.

More information about hormonal birth control is available separately. (See "Patient information: Hormonal methods of birth control".)

• Continuous treatment — Some doctors and nurses advise women with heavy menstrual periods to take hormonal birth control continuously, without a break week. This will allow you to skip your period. This strategy is called continuous dosing.

Several brands of birth control pills are packaged with 3 or 12 months of pills to make it easier to take the pill continuously (table 1). You can also take other types of hormonal birth control continuously. This is explained in detail separately. (See "Patient information: Hormonal methods of birth control", section on 'Continuous dosing'.)

Hormonal intrauterine device — There is an intrauterine device (IUD) that slowly releases a hormone, progestin, into the uterus. There is no estrogen in the IUD. This device is called Mirena in the United States and elsewhere. The IUD prevents pregnancy and reduces menstrual bleeding for up to five years (picture 1). A doctor or nurse places the IUD inside the uterus. This treatment is best for women who do not want to become pregnant in the next six months. (See "Patient information: Long-term methods of birth control", section on 'Intrauterine device (iud)',).

Implant — There is an implant that slowly releases a progestin into your bloodstream. It prevents pregnancy and reduces menstrual bleeding for up to three years. A doctor or nurse places the implant (which is about the size of a match stick) under the skin in the upper inner arm (picture 2). It is called Implanon® in the US and elsewhere. This treatment is best for women who do not want to become pregnant in the next six months. This is explained in detail separately. (See "Patient information: Hormonal methods of birth control", section on 'Birth control implant'.)

Shot — Medroxyprogesterone acetate (Depo-Provera®) is a long-acting form of a progesterone-like hormone, called a progestin. It is a shot given once every three months. This treatment prevents pregnancy and can reduce heavy menstrual bleeding. The shot is best for women who do not want to become pregnant in the next six months.

The most common side effect of medroxyprogesterone acetate is bleeding and spotting, particularly during the first few months. Many women completely stop having menstrual periods after using this treatment for one year. More detailed information about medroxyprogesterone acetate is available separately. (See "Patient information: Hormonal methods of birth control", section on 'Injectable birth control'.)

Antifibrinolytic medicines — Antifibrinolytic medicines can help to slow menstrual bleeding quickly. These medicines work by helping blood to clot. Examples include tranexamic acid (Lysteda®) and aminocaproic acid (Amicar®).

The advantages of antifibrinolytic medicines over other medical treatments are that:

• The medicine slows bleeding quickly (within two to three hours)
• You need to take the medicine only a few days each month
• The medicines do not affect your chances of becoming pregnant

Side effects can include headache and muscle cramps or pain. You should not take antifibrinolytic medicines with hormonal birth control unless your doctor or nurse approves; there may be an increased risk of blood clots, stroke, and heart attack when taken together.

Nonsteroidal antiinflammatory drugs (NSAIDs) — Nonsteroidal antiinflammatory drugs, such as ibuprofen (sold as Motrin® and Advil®) and mefenamic acid (Ponstel®), can help reduce menstrual bleeding and menstrual cramps. You can buy some NSAIDs (including ibuprofen) without a prescription.

NSAIDs are not expensive, have few side effects, and reduce pain and bleeding, and you need to take them only during your menstrual period. You can take NSAIDs in combination with any of the medical treatments discussed here. However, NSAIDs do not reduce bleeding as well other medical treatments.

Progestin pills — Progestin can also be taken as a pill. Progestin pills are sometimes recommended for women who do not ovulate regularly. The usual dose is one pill per day for 7 to 10 days every one to three months. You will have menstrual bleeding within a week or two of the last dose.

This treatment helps to prevent the lining of the uterus from becoming thickened, which can cause excessive bleeding. Progestin pills do not prevent pregnancy.

Gonadotropin-releasing hormone (GnRH) agonists — GnRH agonists are a type of medicine that can be used to temporarily reduce menstrual bleeding. This treatment might be recommended for women who are waiting to have a surgical treatment.

These medicines work by "turning off" the ovaries, causing a temporary menopause. The medicines can be taken for up to six months. GnRH agonists are not usually recommended for longer than six months in a row due to the risk of weakened bones when used for long periods of time.

SURGERY FOR MENORRHAGIA

For women who have growths in the uterus, such as polyps or fibroids, having a treatment to remove the growth can reduce or end heavy bleeding.

Fibroids can be treated by removing them (called myomectomy) or cutting off their blood supply (called uterine artery embolization). These procedures are discussed in depth in a separate article. (See "Patient information: Uterine fibroids".)

Other surgical treatments for menorrhagia include:

Endometrial ablation — Endometrial ablation is a treatment that destroys or removes most of the lining of the uterus. This can reduce heavy menstrual bleeding or cause you to stop having menstrual bleeding. It is not a good option for women who might want to become pregnant in the future.

The treatment can be done in the office or as a day surgery. After the treatment, most women have some cramping, vaginal discharge, and nausea. You may have a pinkish vaginal discharge for two to three days afterward; this gradually becomes clear and watery and can last for 2 to 10 days. Most women can go back to work or school the following day. (See "Patient information: Care after gynecologic surgery".)

Hysterectomy — Hysterectomy is a surgery that removes the uterus. This is a permanent treatment that cures heavy menstrual bleeding. However, the surgery can have complications and requires up to six weeks for full recovery. Pregnancy is not possible after hysterectomy. More detailed information about hysterectomy is available separately. (See "Patient information: Abdominal hysterectomy" and "Patient information: Vaginal hysterectomy".)

WHICH TREATMENT IS RIGHT FOR ME?

There are many treatments for heavy menstrual bleeding, and it can be hard to decide which one is right.

Step one — In most cases, you should start with a medical treatment (using a medicine).

• If you would like to become pregnant in the next several months, a nonsteroidal antiinflammatory or antifibrinolytic medicine might be a good option (see 'Nonsteroidal antiinflammatory drugs (NSAIDs)' above and 'Antifibrinolytic medicines' above).
• If you would like to have children eventually, but not soon, a hormonal birth control method, shot, hormonal IUD, or implant might be a good option (see 'Hormonal birth control' above).
• If you have no plans to become pregnant in the future, you can use any of the medical treatments described above. Hormonal birth control (including the IUD) and antifibrinolytic medicines are probably the most effective medical treatments.

Step two — If you have tried one or more medical treatments and you still have heavy menstrual bleeding, talk to your doctor or nurse. A surgical treatment might be a good option in this case (see 'Surgery for menorrhagia' above).

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed every four months on our Web site (www.uptodate.com/patients).

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information

Patient information: Menstrual cycle disorders (absent and irregular periods)
Patient information: Uterine fibroids
Patient information: von Willebrand disease
Patient information: Warfarin (Coumadin®)
Patient information: Iron deficiency anemia
Patient information: Hormonal methods of birth control
Patient information: Long-term methods of birth control
Patient information: Care after gynecologic surgery
Patient information: Abdominal hysterectomy
Patient information: Vaginal hysterectomy

Professional level information

An overview of endometrial ablation
Chronic menorrhagia or anovulatory uterine bleeding
Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)
Hormonal contraception for suppression of menstruation
Initial approach to the premenopausal woman with abnormal uterine bleeding
Overview of causes of genital tract bleeding in women
Overview of treatment of uterine leiomyomas (fibroids)
Terminology and evaluation of abnormal uterine bleeding in premenopausal women
The evaluation and management of uterine bleeding in postmenopausal women

The following organizations also provide reliable health information.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/ency/article/003263.htm)

[1-4]