menorrhagia

過多月経 　

WordNet

1. abnormally heavy or prolonged menstruation; can be a symptom of uterine tumors and can lead to anemia if prolonged (同)hypermenorrhea

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/08/20 23:38:34」(JST)

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Menorrhagia

Specialty	Gynecology DiseasesDB = 22575
ICD-10	N92.0
ICD-9	627.0
eMedicine	med/1449
MeSH	D008595

Menorrhagia or hematomunia is an abnormally heavy and prolonged menstrual period at irregular intervals. Menorrhagia can be caused by abnormal blood clotting, disruption of normal hormonal regulation of periods, or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods (dysmenorrhea). Fibroids can cause menorrhagia.

Signs and symptoms

A normal menstrual cycle is 21–35 days in duration, with bleeding lasting an average of 5 days and total blood flow between 25 and 80 mL. A blood loss of greater than 80 mL or lasting longer than 7 days constitutes menorrhagia (also called hypermenorrhea). Some authors use menorrhagia exclusively when describing excessive quantity and hypermenorrhea for prolonged duration (although most use both terms interchangeably in the clinical setting). In practice this is not usually directly measured by patients or doctors. Menorrhagia also occurs at predictable and normal (usually about 28 days) intervals, distinguishing it from menometrorrhagia, which occurs at irregular and more frequent intervals. It is possible to estimate the amount of bleeding by the number of tampons or pads a woman uses during her period. As a guide a light tampon will hold 6 mL of blood, a regular tampon will hold 6 to 9 mL of blood, a super tampon will hold 9 to 12 mL of blood, a super plus tampon will hold 12 to 15 mL of blood and an ultra tampon will hold 15 to 18 mL of blood. One may also have lighter cycles in volume, but blood flow may continue more than seven days thus constituting menorrhagia.

Causes

Usually no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. Most common causes include blood disorder or stress-related disorders. A brief overview of causes is given below, followed by a more formal medical list based on the nature of the menstrual cycle experienced.

Disorders of coagulation

With the shedding of an endometrial linings blood vessels, normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies pfa col/epi can also be used to ascertain platelet function abnormalities

Excessive build-up in endometrial lining

Periods soon after the onset of menstruation in girls (the menarche) and just before menopause may in some women be particularly heavy. Hormonal disorders involving the ovaries-pituitary-hypothalamus (the ovarian endocrine axis) account for many cases, and hormonal-based treatments may effectively regulate such disorders.

The lining of the uterus builds up naturally under the hormonal effects of pregnancy, and an early spontaneous miscarriage may be mistaken for a heavier than normal period.

As women age and move towards menopause, ovulation is delayed and the remaining follicles in the ovaries become resistant to GnRH (Gonadotropin releasing hormone) secreted by the hypothalamus gland in the brain. Either that or they don't develop an egg, and thus no progesterone is produced. Without progesterone, the estrogen is "unopposed" and keeps building up the lining of the uterus.

During a woman's period, the endometrial lining which is normally shed never gets the signal to stop thickening. It keeps growing and sheds irregularly. Due to the extra thickness, the bleeding is unusually heavy. Less frequently in this age group, too little estrogen causes the irregular bleeding. Most cases of hemorrhagic are due to normal hormonal changes preceding menopause.

Irritation of the endometrium may result in increased blood flow, e.g. from infection (acute or chronic pelvic inflammatory disease) or the contraceptive intrauterine device (note the distinction from the IntraUterine System which is used to treat this condition).

Fibroids in the wall of the uterus sometimes can cause increased menstrual loss if they protrude into the central cavity and thereby increase endometriums surface area.

Abnormalities of the endometrium such as adenomyosis (so called "internal endometriosis") where there is extension into the wall of the uterus gives rise to an enlarged tender uterus. Note, true endometriosis is a cause of pain (dysmenorrhoea) but usually not alteration in menstrual blood loss.

Endometrial carcinoma (cancer of the uterine lining) usually causes irregular bleeding, rather than the cyclical pattern of menorrhagia. Bleeding in between periods (intermenstrual bleeding or IMB) or after the menopause (post-menopausal bleeding or PMB) should always be considered suspicious.

Consideration by nature of the menstrual cycle

• Excessive menses but normal cycle:
  • Painless:
    • Fibroids (leiomyoma)
    • Ovarian endocrine disorder (dysfunctional uterine bleeding or DUB)(the most common cause)
    • Coagulation defects (rare)
    • endometrial cancer
    • endometrial polyp
  • Painful:
    • Pelvic inflammatory disease
    • Endometriosis
    • Adenomyosis
• Short cycle (less than 21 days) but normal menses (epimenorrhoea or polymenorrhoea). These are always anovulatory cycles due to hormonal disorders.
• Short cycle and excessive menses (epimenorrhagia) due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumours.
• Excessive menses and long intervals.
  • Anovular ovarian disorder due to prolonged estrogen production.
  • This may occur following prolonged continuous courses of the combined oral contraceptive pill (e.g. where several packets are taken without a withdrawal gap in order to defer menstruation).

Differential diagnosis

• Pregnancy complications:
  • Ectopic pregnancy
  • Incomplete abortion
  • Miscarriage
  • Threatened abortion
• Nonuterine bleeding:
  • Cervical ectropion/erosion
  • Cervical neoplasia/polyp
  • Cervical or vaginal trauma
  • Condylomata
  • Atrophic vaginitis
  • Foreign bodies
• Pelvic inflammatory disease (PID):
  • Endometritis
  • Tuberculosis
• Hypothyroidism
• Hashimoto's thyroiditis

Menorrhagia (Fibroid)

ICD-9 codes

Classification of some causes

Cause	ICD-9 code
Polyp of corpus uteri	621.0
Endometrial cystic hyperplasia	621.3
Other specified disorders of uterus, NEC	621.8
Excessive or frequent menstruation	626.2
Puberty bleeding	626.3
Irregular menstrual cycle	626.4
Metrorrhagia	626.6
Disorders of menstruation and other abnormal bleeding from female genital tract, other	626.8
Premenopausal menorrhagia	627.0
Postmenopausal bleeding	627.1

Diagnosis

• Pelvic and rectal examination
• Pap smear
• Pelvic ultrasound scan is the first line diagnostic tool for identifying structural abnormalities.
• Endometrial biopsy to exclude endometrial cancer or atypical hyperplasia
• Hysteroscopy

Treatment

Where an underlying cause can be identified, treatment may be directed at this. Clearly heavy periods at menarche and menopause may settle spontaneously (the menarche being the start and menopause being the cessation of periods).

If the degree of bleeding is mild, all that may be sought by the woman is the reassurance that there is no sinister underlying cause. If anemia occurs then iron tablets may be used to help restore normal hemoglobin levels.

The condition is often treated with hormones, particularly as dysfunctional uterine bleeding commonly occurs in the early and late menstrual years when contraception is also sought. Usually, oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System (IUS) may be used. Fibroids may respond to hormonal treatment, and if they do not, then surgical removal may be required.

Tranexamic acid tablets that may reduce loss by up to 50%. This may be combined with hormonal medication previously mentioned.

Anti-inflammatory medication like NSAIDs may also be used. NSAIDs are the first-line medications in ovulatory menorrhagia, resulting in an average reduction of 20-46% in menstrual blood flow. For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.

A definitive treatment for menorrhagia is to perform hysterectomy (removal of the uterus). The risks of the procedure have been reduced with measures to reduce the risk of deep vein thrombosis after surgery, and the switch from the front abdominal to vaginal approach greatly minimizing the discomfort and recuperation time for the patient; however extensive fibroids may make the womb too large for removal by the vaginal approach. Small fibroids may be dealt with by local removal (myomectomy). A further surgical technique is endometrial ablation (destruction) by the use of applied heat (thermoablation).

In the UK the use of hysterectomy for menorrhagia has been almost halved between 1989 and 2003. This has a number of causes: better medical management, endometrial ablation and particularly the introduction of IUS which may be inserted in the community and avoid the need for specialist referral; in one study up to 64% of women cancelled surgery.

Medications

These have been ranked by the UK's National Institute for Health and Clinical Excellence:

• First line
  • Intrauterine device with progesterone
• Second Line
  • Tranexamic acid an antifibrinolytic agent
  • Non-steroidal anti-inflammatory drugs (NSAIDs).
  • Combined oral contraceptive pills to prevent proliferation of the endometrium
• Third line
  • Oral progestogen (e.g. norethisterone), to prevent proliferation of the endometrium
  • Injected progestogen (e.g. Depo provera)
• Other options
  • Gonadotropin-releasing hormone agonist

Surgery

• Dilation and curettage (D&C) is no longer performed for cases of simple menorrhagia, having a reserved role if a spontaneous abortion is incomplete
• Endometrial ablation
• Uterine artery embolisation (UAE)
• Hysteroscopic myomectomy to remove fibroids over 3 cm in diameter

Complications

Aside from the social distress of dealing with a prolonged and heavy period, over time the blood loss may prove to be greater than the body iron reserves or the rate of blood replenishment, leading to anemia. Symptoms attributable to the anemia may include shortness of breath, tiredness, weakness, tingling and numbness in fingers and toes, headaches, depression, becoming cold more easily, and poor concentration.

Footnotes

General references

• Continuous Identification of Research Evidence (collaborative of the WHO, and US CDC & Johns Hopkins Hospital) - Search of Evidence about the IUS
• Abnormal vaginal bleeding National Guideline Clearinghouse
• Menorrhagia - Menstrual Abnormalities and Abnormal Uterine Bleeding Menstrual Abnormalities and Abnormal Uterine Bleeding - Armenian Medical Network
• Abnormal uterine bleeding/dysfunctional uterine bleeding. Intracorp - Public For Profit Organization. 2005. Various pagings. NGC:004390
• Working group on inherited bleeding disorders rbdd - Rare Bleeding Disorders database
• Project Red Flag Information About Women and Bleeding Disorders
• [1] Adenomyosis Information from MayoClinic.com
• Working group on menorrhagia Menorrhagia and other gynaecological problems in women affected by bleeding disorders

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

• 1. 慢性月経過多または無排卵性子宮出血 chronic menorrhagia or anovulatory uterine bleeding
• 2. 妊娠していない生殖可能年齢の女性における不正子宮出血に対するアプローチ approach to abnormal uterine bleeding in nonpregnant reproductive age women
• 3. 重度または持続性子宮出血のマネージメント managing an episode of severe or prolonged uterine bleeding
• 4. 思春期における異常子宮出血：鑑別診断およびアプローチ abnormal uterine bleeding in adolescents differential diagnosis and approach
• 5. 思春期の異常子宮出血：マネージメント abnormal uterine bleeding in adolescents management

English Journal

• Levonorgestrel intrauterine system--first-line therapy for heavy menstrual bleeding.

• Espey E.
• The New England journal of medicine.N Engl J Med.2013 Jan 10;368(2):184-5. doi: 10.1056/NEJMe1214191.
• PMID 23301736

• Levonorgestrel intrauterine system versus medical therapy for menorrhagia.

• Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J; ECLIPSE Trial Collaborative Group.Collaborators (239)Kai J, Gupta J, Daniels J, Middleton L, Gray R, Pattison H, Gupta J, Kai J, Daniels J, Middleton L, Gray R, Pattison H, Gennard L, Leighton L, Darby E, Gross L, Hills R, Soneja H, Madari S, Snoxall S, Ingram L, Ingram J, Whatmough P, Prileszky G, Warlow C, Pickering O, Sargent S, Bryan S, Roberts T, Sanghera S, Takwoingi Y, Hilken N, Thornton J, Nazareth I, McPherson K, Nicholls E, Mackenzie B, Prentice A, Fountain J, Lumsden MA, Farrin A, Freemantle N, Kulshrestha RP, Kulshrestha S, O'Brien K, Coulson W, Craig J, Descals L, Kownacki A, Montague E, McKenzie B, Spooner CA, Sanganee N, Collier IP, Cope SJ, Goodwin A, Sheldrake LJ, Hanly C, Rajesh R, Hutchon S, Bingham T, Gupta JK, Ingram J, Ingram L, Soneja H, Madari S, Pettinger R, Sadler C, Brown M, Chaffey J, Cowan V, Brain L, Pabla HS, Godridge H, Horner ME, Horton PD, McGhee MF, McGrath M, Sumner KR, Ward-Campbell GJ, Williams S, Madhavan P, Brewin L, Glenchcliffe A, Young DJ, Heslington K, Hunt D, Saikia-Varman N, Jones M, Kavi L, Kidd L, Kai J, Zaman N, Piracha A, Ladha K, Morris M, O'Neill K, Patel JN, Waddell JE, Beighton PG, Cole FH, Edwards RM, Thompson A, Ayres J, Davies J, Poltock TL, Smith M, Talbot H, Cuthbert AJ, Horwell S, Jenkins C, Sinha G, Weaver K, Goodwin B, Patel RP, Debenham SE, Cartmill AD, Parker S, Pennington E, Pennington SJ, Young GB, Butler S, Hamilton PA, Warhad L, Elliott J, Lawrence E, North J, Elliott CI, Jerome S, Shipman PA, Bagchi R, Sheerin N, Blackwall C, Divers V, Siddall J, Parle HJ, Read S, Patodi SK, Amis S, Moloney S, Leung HH, Obi HU, Sidhu M, Ahmed N, Carter SR, Davies W, Harvey H, Khanna K, Rice PF, Shapiro L, Stone J, Parkin T, Craig JM, Moss PJ, Steele V, Cartwright JE, Edward MG, Harrison C, Francis R, Hassall P, Lloyd CE, Haynes J, Budh-Raja S, Budh-Raja VP, Patel SP, Redferne JH, Deb S, Lancaster A, Powell MC, Wragg J, O'Brien DC, Milner S, Taylor DW, Davies D, Tangri AK, Tangri C, Amer S, Prileszky G, Warlow C, Whatmough P, Duncan CH, Bower W, Irani S, Rajput S, Rajput VK, Young K, Cooper RE, Chin K, Scott D, Stacey J, Dadd C, Joshi KG, Sundar K, Broomhead CR, Clarke MP, Sangha E, Wood J, Fitzgerald-Jones B, Harley-Mason GR, Coward AD, Coward CM, Pash J, Little HM, Macdonald AG, Williams JP, Marshall J, McBride H, Watson KA, Clay SN, Walker SA, Billington J, Griffiths H, Mehta R, Emslie CJ, Bath SS, Chiam W, Gordon KR, Latthe M, Nandi DK, Lilford VA, Smith G, Godfrey E, Griffiths S, Porter C, Baird MS, Crombie C, O'Donnell D, Horton V, Kelsey RE, Fletcher JD, Hall F, Lenton C, Allen MP, Heanue J, McDonnell JH, Hancock J, Pattni BL, Banerjee ST, Pate S.
• The New England journal of medicine.N Engl J Med.2013 Jan 10;368(2):128-37. doi: 10.1056/NEJMoa1204724.
• BACKGROUND: Menorrhagia is a common problem, yet evidence to inform decisions about therapy is limited. In a pragmatic, multicenter, randomized trial, we compared the levonorgestrel-releasing intrauterine system (levonorgestrel-IUS) with usual medical treatment in women with menorrhagia who presente
• PMID 23301731

• Hormone releasing intrauterine system should be used more widely in primary care for menorrhagia, study concludes.

• Kmietowicz Z.SourceBMJ.
• BMJ (Clinical research ed.).BMJ.2013 Jan 9;346:f100. doi: 10.1136/bmj.f100.
• PMID 23303890

Japanese Journal

• 1. マイクロ波子宮内膜アブレーション(クリニカルカンファレンス11(女性ヘルスケア)-生殖年齢を過ぎた過多月経患者に対する低侵襲治療について-,生涯研修プログラム,第66回日本産科婦人科学会学術講演会講演要旨)

• 金岡 靖
• 日本産科婦人科學會雜誌 66(9), 2156-2158, 2014-09-01
• NAID 110009844760

• ISP-16-7 Microwave endometrial ablation at a frequency of 2.45 GHz for menorrhagia : Analysis of treatment results at a single facility(Group 16 Women's Health 2,IS Poster,International Session)

• Ishikawa Masako,Nakayama Kentaro,Satoh Emi,Katagiri Hiroshi,Katagiri Atsuko,Rahman Mohammed Tanjimur,Rahmann Munmun,Iida Kouji,Imamura Kayo,Oride Aki,Kanasaki Haruhiko,Miyazaki Kohji
• 日本産科婦人科學會雜誌 66(2), 963, 2014-02-01
• NAID 110009813103

• 働く女性のためのメディカル・ケア (特集 職業関連疾患 : 最新の動向と対策) -- (特論)

• 矢本 希夫,谷本 敏,尾谷 功 [他]
• 日本臨床 72(2), 333-340, 2014-02
• NAID 40019951582

Related Pictures

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★リンクテーブル★

リンク元	「過多月経」「過長月経」「hypermenorrhea」

「過多月経」

　　[★]

英

hypermenorrhea

同

月経過多症、月経過多 menorrhagia

関

月経異常、過少月経、月経

• 月経時の子宮出血が異常に多いもの

病因

• 器質性過多月経

• 子宮筋腫、子宮腺筋症、子宮内膜ポリープ、子宮内膜癌、内膜増殖症
• 血液凝固障害(ITP、白血病など)
• IUDの挿入

• 機能性過多月経：器質的な原因が除外された場合

• ホルモン分泌異常
• 骨盤内のうっ血

「過長月経」

　　[★]

英

menorrhagia, prolonged menstruation, too long menstruation

ラ

menostaxis

関

月経異常、⇔過短月経

• 月経持続日数(出血日数)が8日以上の月経

「hypermenorrhea」

　　[★]

• n.

• 月経過多、過多月経、多発月経

関

menorrhagia