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Am Fam Physician. 2000;62(7):1650-1652

Menorrhagia, or excessive menstrual blood loss, is defined as blood loss of 80 mL per month and can be associated with ovulatory and anovulatory ovarian cycles. The bleeding in the former is regular, while that in the latter is irregular. Ovulatory ovarian cycle is the most common presentation, but ovulatory and anovulatory cycles can cause excessive blood loss, which should not be confused with dysfunctional uterine bleeding. The result of excessive bleeding is iron deficiency anemia. Prentice discusses the evaluation and treatment of menorrhagia.

The evaluation of menorrhagia serves to: (1) assess the morbidity associated with excessive blood loss; (2) exclude major intrauterine disease; and (3) assess the importance of other coexistent disorders. Six investigations are commonly performed for menorrhagia: (1) a full blood cell count to assess extent of blood loss and iron state; (2) a coagulation screen, which is useful only when indicated by the history; (3) thyroid function testing, which is generally not useful; (4) other endocrine testing, which is generally not useful; (5) pelvic ultrasound examination, which is valuable to clarify other pelvic disorders discovered during clinical examination; and (6) endometrial sampling, which is useful in patients older than 40 years, women with intermenstrual bleeding and after a failed trial of medical treatment.

Medical treatment can be divided into non-hormone and hormone therapy (see accompanying table). Because no underlying hormone disorder exists, the use of hormones only controls the cycle. Nonhormone treatments for menorrhagia are more appropriate, with the first-line choices being tranexamic acid and nonsteroidal anti-inflammatory drugs taken during the menstrual cycle. Tranexamic acid reduces blood flow more than nonsteroidal anti-inflammatory drugs. Hormone therapy, such as progestogen taken only during the luteal phase of the cycle, is ineffective. Progestogens are effective when taken for 21 days of each cycle, but side effects may be problematic. The combined contraceptive pill is an effective contraceptive agent and treatment for menorrhagia because it imposes a cycle. The recently licensed levonorgestrelreleasing intrauterine system seems to have better patient compliance because the lower level of hormone release minimizes the progestogenic side effects. However, it is currently labeled only for contraception. Its clinical effect in reducing blood loss occurs by prevention of endometrial proliferation. Irregular bleeding or spotting may occur initially, but most women have a satisfactory result after 12 months of therapy, with only light bleeding or amenorrhea.

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The author concludes that effective medical treatments for menorrhagia exist and that they improve patient choice and provide good alternatives to surgery.

editor's note: Tranexamic acid is a synthetic derivative of the amino acid lysine. It produces an antifibrinolytic effect through the reversible blockade of lysine binding sites on plasminogen molecules. It is administered intravenously (usually 10 mg per kg followed by infusion of 1 mg per kg per hour) and has been widely used in multiple settings of blood loss, including cardiac surgery and upper gastrointestinal bleeding, resulting in a decrease in the requirement for transfusion. In the gynecologic setting, the drug has been used successfully to control bleeding in menorrhagia, placental bleeding, postpartum hemorrhage and conization of the cervix. Tranexamic acid is well-tolerated, with the most common adverse effects being nausea and diarrhea. There has been minimal evidence of increased risk of thrombosis. Tranexamic acid is a useful potential alternative to surgery in patients with menorrhagia and has also been useful to control bleeding in pregnancy.—r.s.

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