Heavy Menstrual Bleeding (Menorrhagia): Causes, Diagnosis, and Treatment

Definition

Menstrual bleeding >7 days or >80 mL blood loss per cycle (soaking pad/tampon every 1–2 hours, passing clots >1 inch).

Common Causes (PALM-COEIN Classification)

• Structural (PALM): Polyp, Adenomyosis, Leiomyoma (fibroids), Malignancy/hyperplasia.
• Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not classified.

Top causes: fibroids (submucosal > intramural), anovulation (PCOS, perimenopause), adenomyosis, coagulopathies (von Willebrand), endometrial polyps, copper IUD.

Diagnostic Workup

• History + menstrual calendar.
• CBC (anemia), TSH, prolactin, coag screen (if indicated).
• Pelvic ultrasound (transvaginal) → saline infusion sonohysterography (SIS) or hysteroscopy for cavity lesions.
• Endometrial biopsy if >45 or risk factors (obesity, unopposed estrogen, tamoxifen).

Treatment (Stepwise)

1. Medical: NSAIDs (reduce flow 20–50%), tranexamic acid (antifibrinolytic), combined OCP, progestin-only (pill, implant, IUD—LNG-IUS most effective), GnRH agonists (short-term).
2. Procedural: Hysteroscopic polypectomy/myomectomy, endometrial ablation (NovaSure, Thermachoice), UAE.
3. Surgical: Myomectomy (fertility-sparing), hysterectomy (definitive, last resort).

Individualize based on age, fertility desires, severity, and etiology.