Heavy Menstrual Bleeding (Menorrhagia)

Heavy menstrual bleeding (also known as menorrhagia) was previously defined as total blood loss > 80 ml per menses, but it is obviously difficult to quantify. The management has therefore shifted towards what the woman considers to be excessive. Prior to the 1990's many women underwent a hysterectomy to treat heavy periods but since that time the approach has altered radically. The management of menorrhagia now depends on whether a woman needs contraception.

Investigations

• a full blood count should be performed in all women
• NICE recommend arranging a routine transvaginal ultrasound scan if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality. Other indications include abnormal pelvic exam findings.

Does not require contraception

• either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
• if no improvement then try other drug whilst awaiting referral

Requires contraception, options include

• intrauterine system (Mirena) should be considered first-line
• combined oral contraceptive pill
• long-acting progestogens (eg. Depo-provera)

Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.

Flowchart showing the management of menorrhagia