Menorrhagia (Heavy Menstrual Bleeding) Treatment Program

Menorrhagia, or heavy menstrual bleeding, is a prevalent gynecological disorder that significantly affects individuals during their reproductive years. It is defined not only by the volume or duration of menstrual bleeding but also by the degree to which it disrupts daily functioning, impairs quality of life, and places a physiological burden on the body. While many patients initially perceive heavy bleeding as a normal variation of the menstrual cycle, persistent or excessive bleeding can have cumulative health consequences, most notably the development of iron-deficiency anemia, which may manifest as chronic fatigue, cognitive impairment, and reduced physical capacity. 

From a clinical standpoint, menorrhagia imposes both personal and healthcare system burdens, contributing to increased medical visits, absenteeism from work or school, and the need for ongoing interventions. Its impact extends beyond physical health, often influencing emotional well-being, intimate relationships, and mental health due to the unpredictability and severity of bleeding episodes. Despite its prevalence, menorrhagia is frequently underreported and undertreated, partly due to normalization of symptoms and lack of early medical consultation. 

Why Cuba  

In Cuba, timely evaluation by a gynecology specialist is essential not only to alleviate the distress caused by excessive menstrual bleeding, but also to identify or rule out underlying gynecological or systemic conditions that may contribute to menorrhagia. The Cuban healthcare system emphasizes a multidisciplinary and individualized approach, where each patient is assessed within a structured clinical pathway designed to preserve both functional and reproductive outcomes. Care is delivered through evidence-based protocols that integrate accessible diagnostic services and tailored treatment strategies, ensuring that the broader impacts on a woman’s physical, emotional, and social well-being are fully addressed. 

Causes of Menorrhagia 

Menorrhagia can arise from a broad spectrum of structural, hormonal, and systemic abnormalities that disrupt the normal balance of endometrial shedding, uterine contractility, and hemostasis. Identifying the underlying cause is crucial for guiding effective treatment. Below are the most common and clinically relevant contributors: 

• Uterine Fibroids (Leiomyomas)
  Benign smooth muscle tumors of the uterus that can distort the uterine cavity by increasing endometrial surface area and interfering with uterine contractility, contributing to menorrhagia and anemia. 

• Endometrial Polyps
  Localized overgrowth of endometrial tissue within the uterine cavity can lead to irregular and heavy bleeding.  

• Adenomyosis
  Endometrial tissue invades the uterine muscle wall (myometrium), resulting in an enlarged, tender uterus and diffuse menstrual bleeding.  

• Hormonal Imbalances
  Estrogen and progesterone regulate the growth and shedding of the endometrium. Imbalances can lead to excessive endometrial proliferation and unpredictable, heavy bleeding.  

• Coagulation Disorders
  Inherited or acquired bleeding disorders may cause or exacerbate heavy menstrual bleeding.  

• Thyroid Dysfunction
  Both hypothyroidism and hyperthyroidism can affect menstrual regularity and volume. Hypothyroidism is more commonly associated with menorrhagia due to its effects on estrogen metabolism and endometrial stability. 

• Pelvic Inflammatory Disease (PID)
  Chronic or recurrent pelvic infections can lead to endometrial inflammation, scarring, and vascular fragility, resulting in intermenstrual or heavy menstrual bleeding.  

• Use of Anticoagulant Medications
  Drugs such as warfarin, heparin, or direct oral anticoagulants (DOACs) may impair clotting mechanisms, contributing to excessive menstrual bleeding even in the absence of structural abnormalities. 

• Endometrial Hyperplasia or Carcinoma
  Prolonged estrogen exposure, especially in the absence of progesterone, may lead to abnormal thickening of the endometrial lining or progression to atypical hyperplasia and endometrial cancer—both of which can present with menorrhagia or postmenopausal bleeding. 

• Idiopathic or Dysfunctional Uterine Bleeding (DUB)
  In many cases, particularly in adolescents or perimenopausal women, no structural or systemic cause is identified. These cases are classified as abnormal uterine bleeding of ovulatory or non-ovulatory origin, reflecting disturbances in the hypothalamic-pituitary-ovarian axis. 

Types and Classification of Menorrhagia 

Menorrhagia is broadly classified based on the presence or absence of identifiable underlying causes. This classification aids clinicians in determining appropriate diagnostic strategies and treatment pathways. 

Primary Menorrhagia 

Primary menorrhagia refers to heavy menstrual bleeding that occurs in the absence of any structural, systemic, or coagulopathic disorder. 

• It is most attributed to hormonal imbalances, particularly in adolescents and perimenopausal women where the hypothalamic-pituitary-ovarian axis is still maturing or becoming irregular. 
• Typically associated with anovulatory cycles, during which ovulation fails to occur, leading to unopposed estrogen stimulation and excessive endometrial proliferation without timely shedding. 
• While not linked to any structural pathology, it can still cause significant anemia and requires monitoring and treastment. 

Secondary Menorrhagia 

Secondary menorrhagia occurs when heavy bleeding results from a clearly identifiable pathological condition, whether anatomical, systemic, or medication induced. 

• Common causes include uterine fibroids, adenomyosis, endometrial polyps, endometrial hyperplasia, or malignancy. 
• It may also be secondary to systemic disorders such as thyroid disease, clotting disorders, or the use of anticoagulant medications. 
• In contrast to primary menorrhagia, secondary cases typically show abnormalities on imaging or laboratory evaluations and may require surgical intervention if unresponsive to medical management. 

Diagnosis of Menorrhagia 

Menorrhagia is a treatable condition, but one that requires timely evaluation to prevent complications and improve quality of life.  

Detailed Medical History 

• Includes menstrual pattern, family history, medications, and any symptoms of bleeding disorders. 

Physical and Pelvic Examination 

• Assesses uterine size, tenderness, or masses.

Laboratory Tests 

• Complete blood count (CBC) – to assess anemia 
• Thyroid function tests 
• Coagulation profile 
• Hormone levels (FSH, LH, prolactin) 

Imaging and Diagnostic Tools 

• Transvaginal ultrasound – to visualize fibroids, polyps, and endometrial thickness 
• Saline infusion sonography (SIS) – enhances uterine cavity imaging 
• Hysteroscopy – direct visualization of the endometrial cavity 
• Endometrial biopsy – especially in women over 35 or with risk factors for cancer

Conservative (Non-Surgical) Treatment Options 

Conservative (non-surgical) treatment options for menorrhagia are typically the first line of management, especially for patients who wish to preserve fertility, avoid surgery, or have mild to moderate symptoms that can be effectively controlled with medication or lifestyle modifications. 

Pharmacologic Therapies  

• NSAIDs (e.g., ibuprofen): Reduce menstrual blood loss and relieve pain 
• Antifibrinolytics (e.g., tranexamic acid): Reduce bleeding by promoting clot stability 
• Hormonal therapies: 
• Combined oral contraceptives 
• Progestins (oral or injectable) 
• Levonorgestrel-releasing intrauterine system (LNG-IUS) 

Iron supplementation 

• Essential to correct and prevent anemia caused by blood loss 

Surgical Treatment Options 

Surgical treatment menorrhagia is generally considered when: 

• Bleeding is severe, persistent, or refractory to medical therapy 
• A structural abnormality is identified that cannot be managed conservatively 
• There is coexisting anemia or risk of complications 
• The patient is not a candidate for, or does not desire, hormonal therapy 
• Fertility is no longer desired, and a definitive solution is preferred 

Types of surgical treatment for menorrhagia include: 

Endometrial Ablation 

• This is a minimally invasive  
• The procedure is performed by destroying the endometrial lining using heat, cold, or electrical energy 
• Ideal for women with no desire for future pregnancy 
• Recovery is quick, with minimal downtime 

Myomectomy 

• The procedure can be minimally invasive (laparoscopic or hysteroscopic) or open surgery 
• The procedure involves the surgical removal of fibroids while preserving the uterus 
• Ideal for women with fibroid-related menorrhagia who wish to maintain fertility 

Hysteroscopic Polypectomy 

• This is a minimally invasive procedure 
• The procedure is carried out by the removal of endometrial polyps via a hysteroscope through the vaginal canal 
• Ideal for isolated intracavitary polyps causing focal bleeding 

 Uterine Artery Embolization (UAE) 

• This is a minimally invasive, image-guided procedure 
• The procedure involves the embolization of uterine arteries to shrink fibroids 
• Ideal for women with symptomatic fibroids who seek a non-surgical alternative to hysterectomy 

Hysterectomy 

• The procedure can be vaginal, laparoscopic, or open 
• The procedure involves the complete surgical removal of the uterus 
• Ideal for women with chronic, unmanageable menorrhagia, large fibroids, adenomyosis, or endometrial hyperplasia 
• A hysterectomy is a definitive treatment with 100% resolution of menstrual bleeding