Menorrhagia

Excessive menstrual blood loss (traditionally >80mL/cycle, though clinical definition now based on patient-reported impact on quality of life) interfering with physical, social, emotional, or material quality of life.

PALM-COEIN classification (FIGO) for causes: structural (Polyp, Adenomyosis, Leiomyoma/fibroids, Malignancy/hyperplasia) and non-structural (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified).

Heavy flow (soaking through protection <2 hours, passing large clots, "flooding"), prolonged duration (>7-8 days), bleeding through onto clothing/bedding, need to double up on protection, symptoms of anemia (fatigue, dyspnea, pallor).

• Assess associated features: intermenstrual/postcoital bleeding (structural cause more likely), pelvic pain/pressure (fibroids, adenomyosis), dysmenorrhea, easy bruising/bleeding elsewhere (coagulopathy, particularly if menorrhagia since menarche).

• FBC: assess for iron-deficiency anemia

• Ferritin: if anemia present

• Coagulation screen: if history suggestive (heavy bleeding since menarche, family history, bruising/bleeding elsewhere), consider von Willebrand disease particularly

• TSH: if other hypothyroid features

• Pelvic ultrasound (transvaginal preferred): first-line imaging, assesses fibroids, adenomyosis, endometrial thickness, polyps

• Endometrial biopsy: if age ≥45, risk factors for endometrial hyperplasia/cancer (obesity, PCOS, tamoxifen use, persistent intermenstrual bleeding), or failed medical management

• Hysteroscopy: if focal intrauterine pathology suspected (polyp) needing direct visualization/treatment

Differentials per PALM-COEIN: fibroids, adenomyosis, endometrial polyp, endometrial hyperplasia/malignancy, anovulatory bleeding (PCOS, perimenopause, thyroid dysfunction), coagulopathy (von Willebrand disease), IUD-related, pregnancy complications (always exclude with pregnancy test in reproductive age).

• First-line (no structural pathology requiring specific treatment, or as symptom control alongside definitive workup):
• Levonorgestrel-releasing IUD (LNG-IUS): most effective medical option, reduces bleeding ~90%, also provides contraception
• Tranexamic acid 1g tds during menses (non-hormonal option): reduces blood loss ~50%
• NSAIDs (mefenamic acid 500mg tds during menses): reduces flow and dysmenorrhea, modest effect
• Combined oral contraceptive: reduces flow, cycle regulation, particularly useful if contraception also desired
• Cyclical oral progestogen (norethisterone): short-term option, particularly for dysfunctional bleeding
• Fibroids: LNG-IUS if cavity not significantly distorted; GnRH agonists (short-term, pre-surgical shrinkage, menopausal side effects limit duration); uterine artery embolization; myomectomy (fertility-preserving); hysterectomy (definitive, if family complete/severe symptoms refractory to other measures)
• Endometrial polyp: hysteroscopic polypectomy
• Adenomyosis: LNG-IUS, GnRH agonists, hysterectomy if severe/refractory and family complete
• Endometrial hyperplasia: progestogen therapy (oral or LNG-IUS) with surveillance biopsy, hysterectomy if atypical hyperplasia/malignancy or failed medical management
• Iron replacement for associated anemia (see Iron Deficiency Anaemia entry)

Referral: gynecology for structural pathology requiring intervention, failed medical management, endometrial hyperplasia/malignancy risk requiring biopsy, or persistent symptoms despite first-line treatment.