Menorrhagia is defined as abnormally heavy or prolonged menstrual bleeding, which may occur as a single episode or chronically. Menstrual blood loss of 80 mL or more per cycle qualifies as menorrhagia. It is a form of dysfunctional uterine bleeding and may result from endocrine or hematologic disorders, stress, certain drugs, or medical procedures.

Emergency interventions

• Evaluate hemodynamic status with orthostatic vital signs.

• Insert a large-gauge IV line for fluid replacement if pulse increases ≥10 bpm or systolic BP decreases ≥10 mmHg, or if there are signs of hypovolemic shock (pallor, tachycardia, tachypnea, cool/clammy skin).

• Place the patient supine with feet elevated, and administer supplemental oxygen as needed.

• Use menstrual pads to estimate bleeding quality and quantity.

• Prepare the patient for a pelvic examination to determine the underlying cause.

History and Physical Examination

• Determine age at menarche, menstrual duration, interval between periods, and date of last menses.

• Ask about changes in menstrual pattern, number of pads/tampons used, clots or tissue, and other associated symptoms.

• Review sexual activity, contraception use, and pregnancy possibility.

• Document pregnancy history, gynecologic infections or neoplasms, prior abnormal bleeding, and response to treatment.

• Assess general health, family history (thyroid, adrenal, hepatic disease, blood disorders), past surgeries, emotional stress, radiation therapy, and drug/alcohol use, including anticoagulants and aspirin.

• Conduct a pelvic examination and obtain blood and urine samples for pregnancy testing.

Medical Causes

Other causes

• Drugs: Hormonal contraceptives may trigger sudden menorrhagia; anticoagulants can increase bleeding.

• Herbal remedies: Ginseng and other herbs can cause postmenopausal bleeding.

• Intrauterine devices (IUDs): Can lead to menorrhagia in some women.

Special considerations

• Monitor for hypovolemia continuously.

• Encourage adequate fluid intake, rest, and avoidance of strenuous activities.

• Record uterine blood loss by tracking the number of pads/tampons used compared to normal periods.

• Obtain blood tests: hematocrit, prothrombin time, partial thromboplastin time, and INR.

Patient counseling

• Explain all procedures and treatment plans clearly.

• Teach which signs and symptoms require immediate medical attention.

• Advise on rest and activity restrictions until bleeding subsides.

Pediatric pointers

Young girls with irregular menstrual cycles may experience hemorrhage and secondary anemia.

Geriatric pointers

Postmenopausal women do not experience menorrhagia; vaginal bleeding in this population often signals endometrial atrophy or malignancy, which must be ruled out.

References

1. Farage MA, Neill S, MacLean AB. Physiological changes associated with the menstrual cycle. Obstet Gynecol Surv. 2009;64:58–72.

2. Mitchell SC, Smith RL, Waring RH. The menstrual cycle and drug metabolism. Curr Drug Metab. 2009;10:499–507.