Women’s Health

Conservative General Measures:

If the bleeding due to menorrhagia is not heavy and consequent anemia is not serious or hemoglobin is normal, the patient should be observed for few months, as in many cases there is spontaneous cure (recovery from menorrhagia) and it should be awaited. If the patient’s menorrhagia is severe there is always some degree of anemia. In this juncture the complete hemogram test should be done instead of doing only hemoglobin estimation. As a conservative measure oral iron preparation should be given to the patient and response to the oral iron checked by serial blood count and hemoglobin estimation (generally at least twice a month, if possible every week). If patient is not responding to iron satisfactorily due to any cause (may be due to iron intolerance, failure to utilize the oral iron etc.), she should be given parenteral iron preparation till anemia is fully corrected and body iron stores become normal. The patient should be reassured and bed rest and sedatives given, which plays important role in conservative management of menorrhagia. If anemia is severe, blood transfusion may be required.

Role of NSAIDs in menorrhagia:

The NSAID (non steroidal anti inflammatory drug) used is mefenamic acid 500 mg three times a day with full stomach. This is given for 5-6 days during menstruation in menorrhagia cases of ovulatory cycles, menorrhagia associated with IUCD, and post sterilization menorrhagia. The common side effects of mefenamic acid are nausea, vomiting, headache, dyspepsia, hemolytic anemia etc.

Role of antifibrinolytic drugs:

The drug which was tried with varying result in menorrhagia is epsilon-amino-caproic acid at the dose of 1-3 grams four times a day for 6-7 days. The side effects that are encountered with epsilon-amino-caproic acid are nausea, vomiting, headache, intracranial thrombosis etc.

Menorrhagia is a presenting symptom in many endocrine diseases. In patients with hyperthyroidism, menorrhagia is a frequent symptom, especially in early stage of the disease. In advance stage of hyperthyroidism patients usually have amenorrhea (absence of menstruation). In hypothyroidism menorrhagia is generally seen in the advanced stage of the disease. Menorrhagia is a common symptom in myxedema (disease of hormonal disturbance), especially in women above 40 years of age. In acromegaly (due to excess production of growth hormone in adults) menorrhagia can be a symptom in early stage and in the late stage usually there is amenorrhea.

Iatrogenic causes of menorrhagia:

Menorrhagia may also develop due to use of estrogen for prolonged period for non gynecological condition (especially use of synthetic estrogen prescribed by dermatologists, for relief of symptoms which is not a gynecological problem). The use may be for long duration and at a dose that may be of high. Estrogen is also frequently prescribed by many doctors for menopausal symptoms, and this prescription (of estrogen) may itself cause menorrhagia. Both of the above instances can be regarded as iatrogenic (caused by doctor’s prescription or hospital acquired).

IUCD as a cause of menorrhagia:

IUCD (intrauterine contraceptive device, used as a method of contraception by women), can also cause menorrhagia as seen in recent times. In fairly large percentage of women using IUCD develop menorrhagia in first few periods after insertion of IUCD and in some women the device has to be withdrawn due to continuation of menorrhagia for long duration.

In approximately 15% of cases of tubectomy (sterilization operation in women in which part of Fallopian tube is removed and both ends are ligated to prevent re-canalization) also menorrhagia is seen although the cause is not clear.

Local pathology in the female pelvis is a common cause of menorrhagia, along with other causes of menorrhagia such as due to general diseases and due to some endocrine disturbance.

In large percentage of cases of menorrhagia the cause is some local pathology in the pelvis. One of the classic examples of local disease in pelvis causing menorrhagia is ‘myoma’ and menorrhagia is the characteristic symptom of myomas. Myomatous polypi are found often during diagnostic curettage while investigating the cause of menorrhagia, so are endometrial polypi found sometimes during investigation of menorrhagia. Inflammation of pelvic area like salpingo-oophoritis (inflammation of ovary and Fallopian tube) also can cause menorrhagia by causing hyperemia.

First menstrual period after childbirth and abortion may be excessive because the uterus is enlarged and not involuted properly. Retroversion of uterus also the menstrual bleeding may be in excess. The symptoms of chocolate cyst may also sometime be menorrhagia, which is also may be due to hyperemia induced by the presence of chocolate cyst. Endometriosis generally does not cause menorrhagia, unless the tumor is estrogenic like granulosa cell tumor.

Symmetrical enlargement of uterus (equal to eight to ten weeks of pregnancy), which is generally due to hyperplasia of uterine musculature, may also be the cause of menorrhagia, as is seen in the pelvic examination of patients. The symmetrical enlargement of uterus is due to excessive estrogen stimulation as seen in adenomyosis. Tuberculosis of emdometrium also presents as menorrhagia in the early stage of disease.