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Case History

image A 35-year-old woman comes complaining that her periods have become increasingly heavy since her children were born. She stopped the pill, which in the past had made her periods lighter, and is now using condoms for contraception. She does not want surgery.

How do you assess her?

What are the non-hormonal treatment options?

What are the hormonal options?


image Menorrhagia is a complaint of heavy cyclical menstrual blood loss over several consecutive cycles without any intermenstrual or post-coital bleeding.1 In objective terms it is a blood loss greater than 80 ml per period.2 While various pathologies have been implicated in menorrhagia, in 50% of cases of objective menorrhagia no pathology is found at hysterectomy. Although 'unexplained' menorrhagia is a very appropriate term, the label dysfunctional uterine bleeding, which implies endocrine abnormalities, is often given. However most cases of menorrhagia are associated with regular ovulatory cycles, and anovular cycles tend mainly to occur soon after the menarche or in the peri-menopausal period. Management has changed over the past two decades with the introduction of the levonorgestrel-releasing intrauterine device. In the United Kingdom the number of hysterectomies for menorrhagia fell by 36% between 1989 and 2002/3.3 Medical management is advocated as initial treatment in women without significant pelvic pathology.2,4

How do you assess her?

Patients with menorrhagia commonly complain of increased menstrual loss requiring more sanitary protection or the passage of clots and flooding. History and assessment are detailed in Table 1.1.

Table 1.1History and assessment

In a woman of this age pelvic pathology is unlikely so if pelvic examination is normal and there are no other symptoms, one can proceed to treat her medically. It is essential to check that she is not anaemic but further tests such as thyroid function should only be undertaken if clinically indicated. However if she does not respond to treatment she will need further investigation starting with a transvaginal ultrasound scan.

What are the non-hormonal treatment options?

Non-steroidal anti-inflammatory drugs

The cyclooxygenase (COX) pathway, with its two enzymes cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2), represents one of the major routes for oxidative metabol ism of arachidonic acid to prostaglandins. Cyclooxygenase inhibitors, commonly referred to as non-steroidal anti-inflammatory drugs (NSAIDs), can ...

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