Menorrhagia treatment. Menorrhagia (heavy menstruation). What laboratory tests should a doctor prescribe for a woman with menorrhagia?

Prolonged and heavy menstruation, which is more like dysfunctional bleeding, is called menorrhagia (synonym: hypermenorrhea). The blood comes out scarlet, almost always with clots, less often - clean.

For comparison: healthy periods last up to 7 days, and with menorrhagia this condition lasts up to 10 days or more. Women do not always go to the doctor because of hypermenorrhea, believing that it is caused by the nature of the body.

Causes of menorrhagia

This pathology may indicate a disease that should be treated. Some of them are serious:

- myomatous nodes (uterine fibroids)

- endometriosis, adenomyosis

- insufficient blood clotting

- dysfunction thyroid gland.

From less hazardous conditions pay attention to the following:

— contraception (intrauterine device)

- intense physical exercise, exhausting diets.

It should be noted that these causes can be called less dangerous only at the beginning of the disease.

Other conditions

Is there some more causal factors, independent of the woman. These include:

- disruption of the ovulation process itself,

- deficiency of female sex hormones.

If the reasons for heavy periods, especially with clots, are based on failures in ovulation, this may be due to:

- excessive activation of the fibrinolytic activity of the endometrium (due to this, blood clotting decreases)

- violation of the biosynthesis of prostaglandins (hormone-like substances); This condition is provoked by: aspirin, butadione, indomethacin.

Causes of the primary form of menorrhagia, with or without clots, include congenital anomalies uterus, leading to an increase in the area of the bleeding surface.

Consequences of untreated menorrhagia

Without taking the necessary measures, constant heavy periods lead to health-threatening consequences:

- anemia

- exhaustion

- metabolic disorders

- diseases of the liver, kidneys, heart.

How does the pathology manifest itself?

Symptoms of menorrhagia with clots are manifested by a large amount of blood released during menstruation and clumps of darker colored tissue that come out with it. In addition to this main symptom, the following are noted:

- extended menstrual cycle (from 10 days)

- volume menstrual blood increases 100 ml/day

- due to large blood loss: dizziness

- lack of appetite, iron deficiency anemia.

Menorrhagia in women is mainly determined by heavy bleeding. If normal periods were previously observed, a secondary type of pathology is diagnosed. Such menstruation may be accompanied by large clots and pain in the lower abdomen. However, such pain can also occur during normal periods; they are considered normal, and therefore are not one of the main signs of menorrhagia.

Diagnosis of hypermenorrhea

When a girl has heavy periods from her first menstruation, they are called primary. This pathology is also treated. Apart from heavy periods, menorrhagia often does not manifest itself in any way, and the woman does not exhibit other symptoms. Then for the exception serious illnesses diagnostics are prescribed to monitor the condition of the epithelium of the uterus, cervix, tubes, and ovaries.

Blood analysis

First of all, it is carried out full analysis blood. Laboratory research reveals such a symptom of hypermenorrhea as altered red blood cells. Almost all of them are smaller than normal and irregular in shape.

An important criterion for assessing menstruation is the amount of blood loss (with or without clots). The only way to measure discharge is by counting the number of pads and tampons. A doctor may ask a woman to keep a diary during her period. You should do this as accurately as possible, and do not forget to make notes and notes daily.

The examination also includes:

- inspection pelvic organs

- thyroid examination

- taking a smear from the cervix

- histology of the endometrium (in women over 40 years old).

For histology, a fragment of the endometrium is taken in one of 2 ways:

- aspiration biopsy (a tip is inserted into the uterine cavity using a syringe, which sucks in a tissue sample)

— diagnostic curettage(carried out under general anesthesia in hospital).

Treatment with drugs

Treatment for heavy periods depends on the presence of a serious disease that led to this condition. If it is detected (for example, fibroids or infection are identified), necessary measures, and menstruation will be restored after the cause is eliminated.

If no serious pathology is detected, menorrhagia is treated medicines. The goal is to reduce bleeding, pain during menstruation, and also bring the duration of bleeding to normal (3-7 days).

In most cases, the doctor prescribes one of 3 regimens:

1. Mefenamic acid, Ibuprofen, Naproxen, Diclofenac.

2. Tranexamic acid preparations.

3. Oral contraceptives of a certain group.

Scheme 1 effectively and quickly copes with heavy periods with and without clots, and normalizes the cycle. However, these drugs have toxic effect on the gastrointestinal mucosa, so their intake is possible only a short time. Method 2 is contraindicated for women diagnosed with thrombosis of any etiology and stage.

Treatment with contraceptives

Significantly reduces the volume of menstrual blood oral contraceptives. Only drugs that contain estrogen and progesterone are prescribed. Together with them, it is possible to take mefenamic acid. This treatment helps eliminate cramps in the lower abdomen during menstruation and regulate the cycle.

The prognosis for treatment is favorable in most cases. The main thing is to consult a gynecologist after the onset of symptoms, that is, after the first case of heavy periods, especially if they have clots. Ignoring this condition can lead to a health hazard.

Surgery: only in rare cases

It is rare that treatment does not help cope with heavy discharge, a hysterectomy (removal of the uterus) is performed. As a rule, women who no longer plan to have children agree to this option. In addition, it makes sense for premenopausal patients to wait until menopause occurs. Then the disease will stop by itself.

The female body is very different from the male body. Thus, representatives of the fairer sex regularly menstruate. This is the absolute norm. The discharge usually lasts up to one week. If this interval increases, then you may have menorrhagia. What it is? You will receive the answer to this question after reading the article. You can also find out what symptoms menorrhagia has. The causes and methods of treatment will be discussed below.

Menorrhagia - what is it?

Most women, having heard this diagnosis in the doctor's office, panicking. You shouldn't do this. Menorrhagia is menstruation that has a slightly different character. Experts characterize this concept as heavy or prolonged periods. Some women suffering from this pathology believe that this is only individual feature body. However, doctors find the cause of the disease in almost all patients who seek help with similar complaints.

Menorrhagia - what is it? This is blood discharge from the genital tract, which occurs in a timely manner and corresponds to the cycle. However, their number is much larger and their duration exceeds one week.

Signs of menorrhagia

What menorrhagia is in women can be easily understood by its symptoms. If you find one or more signs, you should consult a gynecologist as soon as possible. Otherwise, the condition of the fairer sex may deteriorate greatly. The symptoms of pathology are the following:

menstruation lasting more than seven days (usually up to 10 days);
discharge containing clots;
painful sensations in the lower part of the peritoneum and lower back during menstruation;
the secreted blood has a bright scarlet or brown tint;
decreased hemoglobin levels during menstruation;
deterioration of general well-being and decreased performance;
the need to change a pad or tampon every two hours.

Diagnosis of pathology is carried out laboratory methods. The woman is prescribed some tests and studies of her condition. reproductive organs and hormone levels.

Causes of pathology and its treatment

Depending on the causes of menorrhagia, the appropriate correction of this condition is selected. Treatment should be prescribed only after a preliminary examination and consultation with a doctor. Any independent intervention may turn out to be incorrect and only aggravate this process.

Treatment for menorrhagia can vary. In most cases it helps the patient conservative therapy. However, there are also situations when surgical intervention is necessary. Let's look at the main causes of menorrhagia and methods of treating it.

Hormonal diseases

Among the causes are pathologies such as adenomyosis, endometrial hyperplasia and endometriosis. They arise due to excess estrogen in a woman’s body. In this case, the discharge is often accompanied by severe discomfort. Most women with these diseases suffer from long-term infertility. All due to improper release of hormones and proliferation of the mucous layer of the uterine cavity.

Treatment of this pathology in most cases is hormonal. Drugs such as Duphaston, Utrozhestan, Zoladex, and Buserelin are prescribed. Any oral contraceptives can also be used. Only in particularly advanced situations may surgical interventions be necessary. The most common cavity curettage reproductive organ and hysteroscopy.

Disruption of the circulatory system

In some cases, they may be caused by poor blood clotting. At the same time, the woman not only suffers from heavy and prolonged discharge, but also notes heavy bleeding upon receipt of any injury.

Treatment in this case is always chosen individually. Often, a woman is prescribed such compounds as “Tranexam”, “Dicynon”, “Water Pepper” and so on. It is worth noting that some medications cannot be taken regularly. Others are allowed to be used only from the second or third day of the menstrual cycle.

Neoplasms

Another cause of menorrhagia can be a benign or malignant tumor. Most often, patients are faced with the first type of neoplasm. However, they can be in the form of fibroids or cysts located on the ovaries.

Treatment in such situations is most often surgical. Under general or epidural anesthesia, the surgeon removes pathological formation and sends it to Only after this can additional correction be recommended.

Use of contraception

Sometimes the cause of prolonged periods can be incorrectly selected contraception. Often these are oral hormonal drugs and intrauterine devices. If the cause of the pathology lies precisely in this, then the symptoms of menorrhagia appear immediately after the start of such protection from pregnancy.

Treatment in such cases is symptomatic. Doctors recommend immediately stopping using the selected products and consulting a doctor. Doctors will help you suitable drugs, which will not cause such manifestations.

Human factor

Heavy periods may occur due to misbehavior women. If a representative of the fairer sex is involved in professional sports, then during menstruation you need to stop training. Otherwise, such exposure can not only lead to but also cause many health problems.

A variety of diets can trigger menorrhagia. During menstruation and throughout the entire cycle, a woman should eat nutritiously and get the necessary proteins, carbohydrates and fats. If this doesn't happen long time, then dysfunctional bleeding often occurs.

Summing up the article

You have now become aware of such a concept as menorrhagia. What it is is described above. If you suffer from these symptoms, you should contact medical institution. It is almost impossible to independently identify the cause of the pathology and treat it. Only a gynecologist can correctly diagnose and prescribe appropriate correction. Treatment often requires hospitalization in a hospital. Never refuse such an offer. Prolonged absence of treatment can lead to complications. In particularly severe cases it is required complete removal uterus Good health to you!

Menorrhagia is a type of menstrual irregularity in which long periods (more than a week) are observed. uterine bleeding, and the amount of blood released exceeds the physiological norm and is more than 150 ml. Is not independent disease, and the manifestation of different gynecological pathology. Without proper treatment, anemia may develop.

Menorrhagia

Menorrhagia - what is it?

Menorrhagia occurs in almost every third woman. At the same time, they remain unnoticed for a long time. There are primary and secondary forms of this pathology. Secondary menorrhagia occurs after normal menstruation, while primary menorrhagia appears during the first cyclic bleeding.

This pathology must be distinguished from metrorrhagia. It is acyclic (occurring between normal menstruation) uterine bleeding. This is a symptom of dangerous gynecological diseases.

Causes and mechanism of development of menorrhagia

Menorrhagia (hypermenorrhea) occurs due to various reasons. The main risk factors are:

Violation hormonal balance. More often heavy menstruation typical for women of transitional and premenopausal periods. Hormonal imbalance can be caused by diseases of the ovaries (tumors, cysts, oophoritis), pathology of the hypothalamic-pituitary system, thyroid gland and adrenal glands. Often metrorrhagia occurs due to irrational use of hormonal drugs.
Pathology of the female genital organs (cysts, polyps, cervical erosion, benign and malignant tumors, endometritis, cervicitis, salpingoophoritis).
Long-term use of intrauterine devices.
Blood clotting disorder. Possibly due to the use of antiplatelet agents and anticoagulants, a lack of vitamin K in the body, low platelet levels and impaired production of blood clotting factors.
General somatic diseases (hepatitis, nephritis, cardiac pathology).
A sharp change in climatic conditions.
Stress.
Overwork.
Hard physical labor.

Causes of menorrhagia

The pathogenesis of menorrhagia includes the following changes:

violation of control over the renewal of the functional layer of the endometrium (uterine mucosa) by the nervous system;
failure of hormonal regulation;
increased bleeding of blood vessels as a result of weakness of the walls or other disorders.

The development of metrorrhagia is based on completely different processes. In this case, cyclic regulations (bleeding) may not change.

Symptoms and diagnosis of the disease

Hypermenorrhea (excessive blood loss) may be the only symptom. In this case, blood is released out in the form of clots. Often this pathology accompanied by general symptoms in the form of weakness, dizziness and periodic fainting. The reason is blood loss.

With menorrhagia, the duration of bleeding exceeds a week, while physiological norm is 3-7 days. In young girls, menstruation lasts on average 2-4 days. Additional symptoms may include:

Bleeding from other localizations and bleeding gums. Possible if the cause of heavy and prolonged periods is a disease of the blood system.
Pain in the lower abdomen or lower back. Possible with neoplasms.
Difficulty urinating and defecating. It is observed in tumors when the intestines and bladder are compressed.
Pathological discharge between menstruation.
Difficulties in conceiving a child.
Irregular menstruation such as dysmenorrhea (painful bleeding).
Acyclic bleeding.
Discomfort during sexual intercourse.
Signs of intoxication in the body in the form of fever, weight loss and malaise. Observed in chronic infectious pathologies and cancer.

Symptoms of menorrhagia

If you have menorrhagia (heavy and prolonged periods), you need to contact a gynecologist and be examined. To make a diagnosis you will need:

Survey. An obstetric history is collected, as well as the time of the first complaints.
Physical examination (palpation of the abdomen, listening to the lungs and heart, percussion).
Are common clinical tests blood and urine.
Pregnancy test. The level is assessed human chorionic gonadotropin, which increases when a child is conceived.
Vaginal examination on the obstetric chair.
Ultrasound. Allows you to assess the condition of the uterus, Bladder and appendages.
Hysteroscopy ( endoscopic examination uterus).
Cytological analysis. Required if cancer is suspected.
Coagulogram. Helps assess the condition of the blood coagulation system.
CT or MRI.
Examination of smears.
Grade hormonal levels. The blood levels of progesterone, estrogens, follicle-stimulating and luteinizing hormones, and prolactin are determined.
Blood chemistry.
Biopsy.
Analysis for tumor markers. It is carried out if neoplasms are suspected.

Treatment and prevention of pathology

For this pathology, the treatment regimen depends on the causes of heavy and prolonged menstruation. The following medications may be prescribed:

Antihemorrhagic agents (Vikasol, Etamzilat). Vikasol is used for bleeding not associated with organic pathology, lack of vitamin K in the body, low prothrombin levels and in case of uncontrolled intake anticoagulants.
Hemostatics (fibrinolysis inhibitors). These include aminocaproic acid. Used for pathologies of the genital organs to reduce bleeding.
Hormonal drugs(combined oral contraceptives, GnRH agonists, progesterone derivatives). The medicine is selected individually.
Antianemic agents (iron supplements). Ferrum Lek is often used. It is used in solution or tablet form.
Painkillers (NSAIDs, antispasmodics). They are used if hypermenorrhea is combined with pain.

Treatment of menorrhagia

Additionally, rutin and ascorbic acid. After the cessation of menstruation, physiotherapy (complex applications, diathermy) is recommended.

Indications for radical treatment are:

prolonged, recurrent menstruation that cannot be treated with medication;
polyps;
tumors (fibroids, cancer);
erosion.

May require myomectomy (removal of the node), hysterectomy (removal of the entire uterus), supravaginal amputation (removal of the organ while preserving the cervix), panhysterectomy (removal of the uterus with tubes and ovaries). Alternative methods treatments are:

diathermocoagulation;
laser vaporization;
ablation of the endometrium (its partial destruction);
embolization of uterine arteries;
radiation and chemotherapy (used for menorrhagia due to malignant pathology);
exposure to cold (cryodestruction);
radio wave therapy.

Measures to prevent long and heavy periods include maintaining optimal hormonal levels, avoiding IUDs, abortions, hormonal drugs and uterine curettage, treatment of endocrine and infectious pathologies, eliminating stress, correct mode day, timely planning of pregnancy (up to 30 years), regular examination by a gynecologist and management healthy image life.

Menorrhagia is medical term, used to indicate heavy menstruation. A study based on pads and tampons found that the average woman loses 35 ml of blood per menstruation. Menorrhagia is defined as loss of more than 80 ml of blood (above the 90th percentile).

How often does this happen?

Population studies have shown that 10% of menstruating women lose more than 80 ml of blood. Recently, it was discovered that a woman's subjective assessment of blood loss correlates with measured loss better than previously thought.

How often does menorrhagia occur in general practice?

Approximately 5% of women aged 30-49 seek help from their doctor general practice due to excessive bleeding. Therefore, menorrhagia is a condition that a general practitioner must be able to treat effectively. This is also important because until recently, the risk of having a hysterectomy (primarily due to menstrual disorders) during reproductive age was 20%.

What should women know about menorrhagia and how can their doctor help them?

Recently, an interesting study was conducted on how women themselves perceive menorrhagia, how they understand the mechanism of its occurrence and what kind of help they expect from medical workers. The results of a survey of women who consulted their general practitioner about “heavy periods” were assessed. Researchers have found that women have a fairly specific understanding of their symptoms. Changing the cycle itself was already regarded by many women as a problem, without additional criteria. Special attention women paid attention to how they felt and how productive they were, but were not enthusiastic about the doctor’s offer to measure the amount of blood loss. Many of the women were disappointed with the GP's consultation and felt that he had missed the point of their problem. Women were looking for explanations for the reasons for changes in their cycle and did not fully understand what menstrual bleeding was. Those surveyed were unsure whether their problem should be considered a disease and what level of discomfort should be considered normal.

The physician should consider blood loss to be excessive if it reduces the physical, emotional, social, and material quality of life, regardless of the presence of other symptoms. Accordingly, any interventions should be aimed at improving quality of life.

Diagnosis of menorrhagia in women

What is the doctor’s tactics for a woman who complains of heavy menstruation?

The latest evidence-based guidance suggested new approach to the treatment of severe blood loss during menstruation in general practice.

This algorithm assumes that the general practitioner as a first step:

suggest the nature of the bleeding;
evaluate symptoms that may indicate anatomical or histological abnormalities;
will assess the impact on quality of life, as well as other factors that can determine therapy (for example, the presence of concomitant pathology).

What key points should be clarified when collecting anamnesis from a patient complaining of heavy menstruation?

First of all, the degree of blood loss should be determined. It can be difficult for women to measure. Instead of measuring blood loss by pad count, a GP can identify "indicators" by asking the following questions:

How many tampons or pads do you use in a day?
Do you have blood clots?
Have you ever used both a tampon and a pad and still worried about the possibility of leaking?
Did you have the feeling that blood was being released in a continuous stream?

Blood clots, the sensation of leaking blood, and the need to use pads and tampons are also good indicators of menorrhagia.

After this, it is important to find out how regular the bleeding is. This will tell you whether the bleeding is due to an ovulatory or anovulatory cycle, in which dysfunctional uterine bleeding may have occurred. In women aged 36-50 years, heavy menstruation usually occurs against the background of the ovulatory cycle and is caused by myomatous nodes. 80-90% of women with heavy menstrual bleeding have regular cycles (lasting 21-35 days). In women with prolonged irregular or intermenstrual bleeding, 25-50% of cases have submucosal myomatous nodes or endometrial polyps (assessed in carefully selected patients). The incidence of submucosal nodules and polyps in women with regular, heavy menses is unknown.

Irregular and inter menstrual bleeding in contrast to regular ones, they often indicate the presence of pathological changes.

Very rarely, menorrhagia can be caused by bleeding disorders. However, laboratory studies have shown that women with menorrhagia have increased fibrinolytic activity and increased production of prostaglandins in the endometrium. These observations served as the basis for the introduction of some new approaches to the treatment of menorrhagia.

The third step is to find out how much the symptoms affect ordinary life women. Is she up to the job? family life and everyday worries during menstruation? Does she have to constantly make sure there is a toilet or bathroom nearby that she has to go to because of the bleeding? The answers to these questions will allow the general practitioner to understand how urgent the situation is.

Ultimately, the general practitioner must assess the likelihood of anemia. In Western countries, menorrhagia is the leading cause of iron deficiency and anemia. Therefore, a decrease in hemoglobin concentration objectively reflects the severity of blood loss during menstruation.

What medical history data allows the doctor to suspect the presence of pathology?

Structural abnormalities of the uterus, such as endometrial polyps, adenomyosis, and leiomyomatosis, are the most well-known causes of excessive uterine bleeding. The physician should be alert to features in the medical history that indicate the presence of organic pathology And malignant neoplasms, and remember that the risk of endometrial cancer begins to increase after 40 years of age.

Risk factors for endometrial hyperplasia in premenopause include:

infertility or absence of pregnancies;
exposure to excess endogenous estrogens or exogenous estrogens/tamoxifen;
PCOS;
obesity;
a family history of endometrial or colon cancer.

The risk of endometrial hyperplasia and cancer with heavy menstrual bleeding is:

4.9% for all women;
2.3% in women under 45 years of age and weighing less than 90 kg;
13% in women weighing more than 90 kg;
8% in women over 45 years of age.

If a woman has no history indicating a risk of anatomical or histological pathology, then during the first visit it is possible to prescribe drug treatment without the need for physical or other examinations. The exception would be the placement of a LV-IUD or a scheduled Pap smear test. If there is a history of heavy menstrual bleeding combined with intermenstrual or postcoital bleeding, pelvic pain, dyspareunia, and/or tension symptoms, a physical examination and/or other studies (eg, ultrasound) should be performed to rule out malignancy or other pathology. .

When should a doctor conduct an examination?

Many, remembering old proverb“What you don’t look for, you won’t find,” it is recommended to conduct a gynecological examination in all women with menorrhagia.

NICE guidance states that an examination is required if:

if the general practitioner believes that the medical history indicates a possible pathology;
if a woman decides to install a LV-IUD (examination is necessary to assess the possibility of inserting a device into the uterus);
if the woman is referred for further testing, such as an ultrasound or biopsy.

If a woman has myomatous nodes palpated through the abdominal wall, or identified in the uterine cavity during ultrasound or hysteroscopy, and/or the length of the uterine body is more than 12 cm, she should be immediately sent for consultation with a specialist.

What laboratory tests should a doctor order for a woman with menorrhagia?

Because there are many various methods studies, you should carefully approach their prescription and remember that in 40-60% of women the cause of menorrhagia cannot be detected (in such cases, uterine bleeding is regarded as dysfunctional (of unknown etiology)).

Clinical manifestations of anemia do not correlate with hemoglobin levels except in moderate to severe cases. Therefore, all women with heavy menses should have a general analysis blood. Routine determination of iron levels is not recommended, since hematological indices usually provide sufficient insight into the status of iron stores. In women with severe anemia, the likelihood of pathology is increased, and they should be immediately referred to a specialist. Tests for coagulopathy should only be performed if a woman has been experiencing heavy menstruation since menarche or if there is a personal or family history of coagulation disorders. Rate the level female hormones not justified. A study of thyroid hormone levels is indicated only if there are signs of thyroid disease.

Recommendations regarding the most commonly performed laboratory tests for menorrhagia

All women with menorrhagia should have a complete blood count done. In parallel, treatment for menorrhagia should be prescribed.
Screening for coagulopathies (eg, von Willebrand disease) should be considered in women who have had menorrhagia since menarche or have a personal or family history of coagulation disorders.
Serum ferritin measurements should not be routinely administered to all women with menorrhagia.
Women with menorrhagia should not have female hormone levels tested.
A study of thyroid hormone levels is indicated only if there are signs of thyroid disease.
In the case of menorrhagia, serum ferritin levels do not provide more information than can be obtained from a complete blood count.

What is the role of ultrasound in evaluating a woman with heavy bleeding?

There is strong evidence supporting ultrasound as the first-line method for detecting structural abnormalities. It is non-invasive and painless method choice for women who need additional testing. Using ultrasound, you can determine the thickness of the endometrium (in premenopausal women, the normal limit is 10-12 mm), identify polyps and nodes.

There is strong evidence to support the use of transvaginal ultrasound as the first-line diagnostic method in the evaluation of women with menorrhagia.

This examination should be carried out in the following cases:

if the uterus is palpable through the abdominal wall;
if a vaginal examination reveals a formation in the pelvic cavity of unknown origin;
if drug treatment is ineffective.

What is the role of hysteroscopy and biopsy?

Hysteroscopy as diagnostic procedure should be carried out only if the ultrasound conclusion is ambiguous, for example, to accurately determine the location of the myomatous node or clarify the nature of the detected anomaly.

A biopsy is needed to rule out endometrial cancer or atypical hyperplasia. Indications for biopsy are:

persistent intermenstrual bleeding;
disappearance or initial lack of effect from treatment in women 45 years of age and older.

You should not use only curettage of the uterine cavity as a diagnosis.

Which women should be referred for endometrial testing?

It is not entirely clear which women should be referred for endometrial testing and what type of testing should be done. New Zealand guidelines recommend transvaginal endometrial ultrasound in the following women:

with a body weight of more than 90 kg;
over 45 years of age (according to English guidelines, additional examination is recommended after 40 years of age);
with other risk factors for endometrial hyperplasia or cancer, such as a diagnosis of PCOS, infertility, nulliparity pregnancies, exposure to excess estrogen, or a family history of endometrial or colon cancer.

If endometrial thickness is greater than 12 mm on transvaginal ultrasound, an endometrial sample should be taken to rule out hyperplasia. If transvaginal ultrasound is not available, an endometrial sample should also be obtained. For women with irregular menstrual bleeding, lack of response to drug therapy, and signs of pathology on transvaginal ultrasound (polyps or submucosal myomatous nodes), hysteroscopy and biopsy are indicated. As a diagnostic procedure, hysteroscopy and biopsy are more informative. An alternative to biopsy is endometrial aspiration biopsy. The procedure is performed blindly and, despite greater comfort for the woman, it remains controversial whether it can replace hysteroscopy with sufficient levels of sensitivity and specificity.

Endometrial thickness greater than 12 mm may indicate hyperplasia.

Treatment of menorrhagia in women

Should all women with menorrhagia be prescribed iron tablets?

During normal menstruation, bleeding lasts 4 ± 2 days, during which an average of 35-40 ml of blood is lost - an amount equivalent to 16 mg of iron. The recommended intake of iron with food is enough to compensate for 80 ml of blood loss per month. However, the average woman does not consume enough iron in her diet, which means that anemia can develop when she loses 60 ml of blood per month. In most cases, the main symptom that worries women with heavy uterine bleeding is weakness due to anemia. To treat anemia, you should consume 60-180 mg of elemental iron per day.

What treatment can a GP prescribe for women with menorrhagia?

Drug treatment is prescribed if there are no signs of anatomical or histological pathology or there are myomatous nodes less than 3 cm in diameter that do not cause expansion of the uterine cavity.

As shown in the clinical case, the general practitioner should prescribe a woman some treatment to reduce blood loss before, if necessary, she is examined by a gynecologist. There are many options available to your GP, including NSAIDs, hormone therapy(COC or cyclic administration of gestagens), tranexamic acid and even Mirena - LV-IUD. If drug treatment is prescribed for the duration of the study and organization radical treatment, tranexamic acid and NSAIDs should be used.

Drug therapy for menorrhagia is very effective and should be administered by a general practitioner.

There are several factors influencing the choice of therapy:

the presence of ovulatory or anovulatory cycles;
need for contraception or desire to become pregnant;
patient preference (specifically, how satisfied she is with the use of hormone therapy);
contraindications to therapy.

If, based on the medical history and examination results, hormonal or non-hormonal drug therapy is indicated, it should be prescribed in the following order:

preferably long-term (at least 12 months) use of the LV-IUD;
tranexamic acid, NSAID or COC;
norethisterone or long-acting injectable progestogens.

Danazol should not be used routinely to treat heavy menstrual bleeding.

Recommendations for prescribing drug therapy for heavy menstrual bleeding

Women who are planning to have a LV-IUS inserted should be warned about the possibility of changes in bleeding patterns, most often in the first few cycles, sometimes lasting more than 6 months. They should endure at least 6 cycles in order to evaluate the beneficial effect of treatment.
When heavy uterine bleeding is combined with dysmenorrhea, NSAIDs are preferable to tranexamic acid as a treatment.
The use of NSAIDs and/or tranexamic acid should be continued as long as the woman feels benefit from them.
The use of NSAIDs and/or tranexamic acid should be discontinued if no improvement is observed within three menstrual cycles.
If initial therapy is ineffective, instead of immediate referral to surgery a second line should be considered.
Progestogens given orally only during the luteal phase of the cycle should not be used to treat heavy menstrual bleeding.

The two main first-line treatments for menorrhagia, the antifibrinolytic tranexamic acid (Cyclocapron) and non-hormonal NSAIDs. The effectiveness of these drugs has been proven in randomized trials and systematic reviews.

For women who are not planning pregnancy and who can undergo drug therapy As a first choice, the installation of a LV-IUS can be recommended.

For ease of understanding, a general practitioner may tell their patients that tranexamic acid reduces blood loss during menstruation by half, and NSAIDs by about a third. For most women seen by a GP, this explanation will give hope that they will be able to return to their 'normal' periods and there will be no need for surgery. Both types of drugs have the advantage of requiring use only during menstruation (which promotes better adherence) and are especially suitable for women who do not require contraception and who do not want to take hormonal therapy. These types of therapy are also effective for increased menstrual bleeding due to the use of non-hormonal intrauterine contraceptive devices.

What is the mechanism of action of tranexamic acid, its side effects and contraindications for use?

Tranexamic acid inhibits the activation of plasminogen and suppresses the fibrinolytic activity of the blood. Reviews have shown that correct use tranexamic acid (taken with the onset of bleeding) for 2-3 cycles reduced the loss of menstrual blood by 34-59%. Adverse events such as nausea, vomiting, diarrhea and dyspepsia were reported in 12% of women. Unlike NSAIDs, tranexamic acid had no effect on dysmenorrhea. Contraindications include venous thromboembolism or a history of stroke, acquired color vision impairment.

It is also important to note that tranexamic acid:

does not affect dysmenorrhea/pain associated with bleeding, so additional analgesia may be required;
does not have a contraceptive effect, so additional contraception may be required;
does not regulate menstrual cycle, so additional counseling and treatment may be required if necessary.

How should NSAIDs be prescribed to treat menorrhagia?

Any NSAIDs can be used, but the most commonly prescribed are:

mefenamic acid (Ponstan);
diclofenac (Voltaren);
naproxen (Naprosyn).

A woman should take the pill only during her menstrual period. For dysmenorrhea, for maximum effectiveness, you should try to start taking it when your menstruation should begin. The general practitioner should be alert to contraindications to NSAIDs. These include:

ongoing gastrointestinal bleeding or ulcers;
inflammatory bowel diseases;
a history of hypersensitivity (asthma, angioedema) caused by taking aspirin or NSAIDs;
impaired renal or liver function.

How beneficial is hormone therapy?

Traditionally, hormonal therapy for menorrhagia has involved the use of progestogens given during the luteal phase of the cycle. Progestins effectively reduce blood loss only if they are prescribed within 21 days of each cycle. However, complications of such therapy can lead to patients refusing to continue it.

COC therapy is perhaps more familiar to a general practitioner. In the absence of contraindications, the use of COCs produces a beneficial effect in menorrhagia. In addition to providing contraception, the drugs significantly reduce the amount of blood lost during menstruation. The general practitioner can choose the most suitable for woman pills. For example, if levonorgestrel does not sufficiently reduce bleeding, you can try a drug containing norethisterone or third-generation progestin-containing contraceptives. The doctor may also suggest that the woman skip the packaged pacifiers and drink hormonal pills continuously - this will give good vacation from menstruation. COCs are also effective for anovulatory bleeding because they regulate the cycle.

Due to its economic feasibility for long-term use, the preferred and definitive method of therapy is the LV-IUD (Mirena). It is a T-shaped base coated with a reservoir of levonorgestrel, released at a rate of 20 mg per day. Thanks to this low level systemic hormones are minimized side effects gestagens. Therefore, patients are more likely to continue this therapy than cyclic progestogens. The IUD exerts its effect by reducing endometrial proliferation and, as a result, reducing the duration and severity of bleeding. Up to six months and especially in the first three months after installation of the system, the patient may be bothered by irregular bleeding and scanty spotting, but by 12 months. most experience only minor bleeding or develop amenorrhea. Many of the problems associated with bleeding and scanty bloody discharge, can be overcome with careful pre-counseling.

What are the principles of surgical treatment?

Drug treatment of menorrhagia in no way excludes the possibility of surgical intervention as the next step. However, a conservative approach can give a woman time to recover from “heavy periods” and consider all possible options further treatment, including surgery. If drug treatment was not used, then the woman may decide that surgery is the only way out of the difficult situation in which she finds herself. For many women, hysterectomy actually serves best choice, meaning the cessation of the need for treatment of menorrhagia.

Important

A third of women complain of heavy menstruation, but only 10% have menorrhagia.
Until recently, 20% of women in late reproductive age had to have their uterus removed.
The main cause of heavy bleeding is anovulatory cycles and uterine fibroids.
Risk factors for endometrial hyperplasia and cancer in premenopausal women include infertility and pregnancy loss, exposure to excess endogenous or exogenous estrogens or tamoxifen, PCOS, obesity, and a family history of endometrial or colon cancer.
All women with metrorrhagia should have a complete blood count performed.
Drug therapy for menorrhagia is very effective.
Tranexamic acid reduces blood loss during menstruation by half, and NSAIDs - by about a third.
Progestogens are effective for menorrhagia only if they are given for at least 21 days.
COCs and LV-IUD Mirena are also effective in the treatment of menorrhagia.
If, based on medical history and examination results, hormonal or non-hormonal drug therapy is indicated, insertion of a LV-IUD would be the preferred method for long-term use.

Menorrhagia (hypermenorrhea) is prolonged and heavy uterine bleeding during menstruation, the interval between which is significantly reduced.

In women suffering from menorrhagia, menstruation is usually long (7 or more days), and the patient loses about 100 ml of blood.

The main symptom of menorrhagia is not only copious discharge blood, but also the presence of clots in it.

Large blood loss sometimes provokes a complication such as anemia. After heavy menstruation, this is a fairly common phenomenon in which a woman develops:

- feeling of weakness,
Deterioration in health
Dizziness,
Fainting state.

Sometimes menorrhagia causes bruising and bleeding on the body, as well as bleeding gums and nosebleeds. In this case, menstrual bleeding is so heavy that a woman has to change sanitary pads or tampons every hour. Every woman should know that excessively heavy menstruation is a reason to contact a professional who will help solve this problem.

Why does menorrhagia occur?

The following disorders can cause menorrhagia:

- hormonal disbalance, especially in adolescents and women of premenopausal age;
Diseases of the female reproductive system (fibroids, polyps, uterine adenomyosis) caused by hormonal imbalance in a woman's body;
Complications when using intrauterine contraceptives;
Poor blood clotting resulting from vitamin K deficiency, thrombocytopenia, or taking medications that affect blood clotting;
Diseases of the thyroid gland, liver, heart and kidneys can cause the development of menorrhagia.

That is why, in case of heavy menstruation, the specialists of our clinic recommend consulting a therapist and an endocrinologist in order to exclude general somatic and endocrine causes bleeding and any factors that force the body to activate mechanisms of adaptation to new conditions (excessive stress, sudden climate change) provoke the development of menorrhagia.

In addition, menorrhagia is often inherited through the female line.

Diagnosis of menorrhagia

In case of any bleeding, the doctor must initially exclude pregnancy in the patient, especially ectopic pregnancy. To do this, in the laboratory of our clinic you need to take a blood test for pregnancy (to detect the hormone human chorionic gonadotropin in the blood).

To find out the causes of menorrhagia, the doctor examines the female genital organs.

During the inspection, the possible presence of:

- tumors;
Polypov;
Foreign bodies;
Inflammatory processes;
Traumatic injuries.

If there is any suspicion of various pathologies uterus or ovaries, the doctor, in addition to ultrasound, prescribes a biopsy, hysteroscopy, endometrial tissue analysis and curettage.

The technical base of our clinic’s laboratory allows us to examine the patient’s blood:

- for hemoglobin;
For clotting;
To determine hormonal levels;
Not tumor markers.

If the patient's menstruation is too heavy, then it is recommended that she keep a menstrual calendar to note the duration, nature and abundance of the discharge.

How is menorrhagia treated?

In their practice, doctors at our clinic use two methods of treating menorrhagia:

- therapeutic (medicinal);
Surgical.

Drug treatment includes taking anti-inflammatory drugs and hormonal contraceptives in combination or separately. Hormonal preparations contain the hormones estrogen and progesterone, which prevent the growth of the endometrium and thus reduce the volume of discharge.

Anti-inflammatory drugs are very effective in treating menorrhagia, but in some patients they provoke irritation of the gastric mucosa.

The surgical method of treating menorrhagia is used for:

- damage to the genital organs or their physiological disorders;
Recurrent menorrhagia;
Iron deficiency anemia.

If drug treatment for menorrhagia is ineffective, doctors use the following surgical procedures:

1) Removal of the uterus (hystrectomy). This operation makes pregnancy impossible, so it is very rarely performed on women. reproductive age. After a hystrectomy, a woman’s body recovers quite quickly.
2) Inspection of the walls of the uterus using a special instrument. Using this procedure, it is possible not only to diagnose violations, but also to eliminate them. Before the examination, the doctor prescribes a test for hepatitis B, syphilis, and determination of the patient’s blood group and her Rh factor. Treatment of menorrhagia with this method is effective in approximately 80 percent of cases.

Every woman should remember that menorrhagia is serious illness. Treatment must be immediate. Therefore, under no circumstances should you postpone a visit to the doctor in order to avoid irreversible consequences. Be attentive to your health!