What is Menometrorrhagia?
Menometrorrhagia is a Latin term for irregular menstrual bleeding which occurs during menstruation or during any time in menstrual cycle. There are two other terms : Menorrhagia is a prolonged and excessive menstrual bleeding. Metrorrhagia is irregular abnormal bleeding without any link to menstruation.
All three terms could mean that there is a problem with the amount of blood (more than 80ml during one menstrual cycle), which is excessive or lasts longer than 7 days but isn’t necessarily excessive. This bleeding may not be severe, but still require some medical attention.
Some are however very severe and may be the cause of the hypotensive shock. Normal bleeding occurs with first day of menstrual cycle (in average is 28 days), and lasts between 3 and 7 days.
The prevalence of menometrorrhagia is around 12% of women, and the incidence increases with age. (1)
Figure 1 – Bleeding from the uterus
Pathophysiology of bleeding may be simple if the cause is some type of injury, tumour or presence of device, however, the hormonal imbalances are differently analysed. Some abnormal bleedings with hormonal imbalance are normal in young girls, but this is not to be taken as a rule. These are the possible causes of menometrorrhagia:
- Hormonal imbalance may cause endometrial hypertrophy and the bleeding is prolonged because the body attempts to get rid of this tissue,
- Pregnancy or miscarriage may both present with bleeding,
- Dysfunction of ovaries and absence of ovulation (anovulatory cycles) and undevelopment of corpus luteum and lack of progesteron may also present as the endometrial hypertrophy,
- Uterine tumors (polyps, fibrinoid tumours, myomas) are the most common cause of bleeding not only in women older than 35, because the recent prevalnce showed myomas even in women who are between 20 and 30 years old,
Figure 2 – Polypus in the fundus of the uterus that could be the reason for bleeding
- Ovarian cyst or cancer,
- Adenomyosis and endometriosis – abnormal endometrial tissue in the the muscle layers of the uterine wall or in other surrounding organs,
- Injuries and intrauterine devices,
- Cancers of the cervix or adenocarcinoma in the uterus,
- Bleeding disorders and coagulopathies,
- Some medications (corticosteroids, hemotherapy),
- Other conditions for example hypothyreoidism, hyperthyreoidism and obesity, which may induce bleeding with complex mechanisms. (1) (3)
Signs and symptoms of menometrorrhagia are usually:
- Bleeding that lasts for more than 7 days, in most cases between two menstrual cycles
- Bleeding that is excessive and with large blood clots on pads
- Menstrual cycle which is less than 21 days or more than 35 days
- Pain in the abdomen, back pain and fatigue
- Signs of excessive bleeding, hypotension, paleness, anaemia, tachycardia. (3)
Much of the information are received from the patient’s history. A woman complains about the bleeding during menstruation or regardless of the menstruation. Information about the previous bleedings, chance for pregnancy, bleeding disorders would be helpful.
A doctor will perform a clinical exam, for example palpate abdomen to check for any abdominal masses that could be the reason for bleeding. Pelvic exam and Papanicolau smear are also necessary to rule out the sources from the outer portion of the genitalia.
Other diagnostic procedures are endovaginal ultrasound, lab tests (hormones: prolactin, estrogen, progestin, testosterone; coagulation factors, aPTT, PT, TT and bleeding time, complete blood count). Hysteroscopy is a procedure in which a doctor can enter uterine cavity with specific instruments.
Menometrorrhagia needs to be differentiated from Menorrhagia and Metrorrhagia. They can mean different things but can also appear as associated conditions.
Management of bleeding is necessary even though the treatment also needs to be by cause. Some bleedings will stop spontaneously, but there is still needs to be some caution, if the bleeding is excessive. Bleeding may be stopped with application of cold or ergometrine drops (levonorgestrel).
A bottle is filled with cold water, and put on the abdomen in order to constrict the blood vessels. However this method is rarely helpful. In many cases is recommended to use oral contraceptive pills or progestin therapy as the first line of treatment for bleeding to induce endometrial atrophy.
NSAID analgesics are only used in some cases. They are not used here as analgesics but rather as prostacyclin inhibitors, to improve the function of clotting mechanism that stops the bleeding.
There are some methods which are also somewhere used and include herbal therapy. It isn’t recommended to base the whole treatment with this type of management, but rather to use them as additional therapy.
Other treatments include the use of gonadotropin-releasing hormone (GnRH), Danazol, estrogen, tranaxemic acid (Transamin), surgery (hysteroscopy, laparoscopy), dilatation and curettage, resectopic endometrial ablation, cryoablation and others. (2)
Treatment of hypovolemic hypotensive haemorrhagic shock includes saline infusion or blood transfusion.
Prognosis depends on the aetiology of bleeding and quick response to therapeutical measures. Rare occasions of bleeding are usually harmless, and continuous episodes of excessive blood loss may have fatal outcome.
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