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Systemic Disease

  1. Coagulation disorders, for example, ITP, vWD (important cause for puberty menorrhagia)
  2. Hypothyroidism/hyperthyroidism
  3. Liver disease

Iatrogenic Causes

  1. Steroids
  2. Anticoagulants
  3. Intra-uterine contraceptive device (IUCD)

Causes of Contact Bleeding

  1. Carcinoma cervix
  2. Mucous polyp of cervix
  3. Vascular ectopy of cervix specially during pregnancy, pill use
  4. Infections-chlamydial or tubercular cervicitis
  5. Cervical endometriosis

Important Causes Of Menorrhagia In Different Age Groups


Reproductive Age


 HPO axis immaturity

Pregnancy-related complication

(incomplete abortion)

 Endometrial hyperplasia,


 Dysfunctional uterine bleeding (DUB)

Fibroids, polyps, adenomyosis, endometriosis

 DUB, infrequent ovulation

 Coagulation defects (ITP, von

 Willebrand disease)


 Endocrine problems

 Endocrine abnormalities

Endocrine abnormalities

 Fibroids, polyps, adenomyosis,



Type of Dub

DUB is of two types:

  1. Anovulatory (80%)
  2. Ovulatory (20%)

Anovulatory (80%):

  • Threshold bleeding of puberty menorrhagia
  • Metropathia hemorrhagica / cystic glandular hyperplasia
  • Premenopausal DUB (Atrophy of endometrium).

Ovulatory (20%):

  • Irregular ripening of corpus Luteum
  • Irregular shedding of corpus luteum/Halban's disease
  • IUCD insertion
  • Following sterilization operation.

Management of Menorrhagia in Different Age Groups

1. Ultrasonography should be done in all age groups.

2. Sr. TSH should also be done for all patients.

Diagnostic Rules in DUB


Patient with abnormal bleeding

R/O Pregnancy related

b-hCG + USG

R/o. Coagulopathy

Blood test

R/o Pelvic lesions


R/o Malignancy

Cancer markers, TVS, FNAC

R/o Hypothyroidism

Thyroid function test

DUB (Diagnosis of exclusion)

Medical Management of Dub (According To Age Group)

 Age group



I. Puberty menorrhagia

Since in this age group bleeding is usually anovutatory

DOC=cyclical progestin therapy (Leon speroff 8/e, 607)

• Rule out bleeding disorders by coagulation studies, CSC, platelet count

• TSH levels


 Note These 2 investigations

 USG & TSH should be done in

 all groups

• If female has been sexually active

 Uring pregnancy test

 Cultures for gonorrhea,

 Trichomonas, and Chlamydia testing

 Investigation never done in this

 age group

 PN examination

 Dilatation and curettage

• Reassurance

• Psychological support

• Correction of anemia




• In patients with von Wille brands disease, Desmopressin is the DOC

• In young sexually-active females, Levonorgestrel IUCD- Mirena can also be used.

ii. Reproductive age

- (In this age group, it is necessary to

rule out pregnancy complications,

fibroids, polyps and premalignant

conditions like endometrial

hyperplasia and CIN)




• Endometrial sampling (by dilatation & curettage/ hysteros copy & biopsy)

• Papsmear

• Colposcopy


1. Antifibrinolytic drugs like tranexamic acid

2. Prostaglandin synthetase inhibitor-mefenamic acid

3. To stop bleeding: Norethisterone Preparations (5 mg TDS x 5 or 7 days). Then regulate cycle by using either OCPs (in case of ovular bleeding) or medroxy progesterone acetate (In anovular bleeding from D5-D25)


4. Cyclic Therapy

a. In ovular bleeding where patient doesnot want pregnancy: Any low dose combined oral pills are effective when given from 5th to 25th day of cycle for 3 consecutive cycles. It causes endometrial atrophy. It is more effective as compared to progesterone therapy as it suppress the hypothalamo-pituitary axis more effectively and has contraceptive benefits also.

'Treatment with an estrogen progestin contraceptive is the better choice for those who likely still ovulate or want to avoid pregnancy ."

-Leon speroff 8TH /ed p 607


b. In ovular bleeding, where the patient wants

pregnancy or in cases of irregular shedding

or irregular ripening of the endometrium:

Dydrogesterone 1 tab (10 mg) daily or twice a day from 15th to 25th day may cure the state.


c. In anovular bleeding: Cyclic progestogen preparation of medroxyprogesterone acetate (MPA) 10 mg or norethisterone 5 mg is used from 5th to 25th day of cycle for 3 cycles.



Continuous progestins Therapy


Continuous progestins: Progestins also inhibit pituitary gonadotropin secretion and ovarian hormone production. Continous therapy can be in the form of oral therapy or Mirena

a. Medroxyprogesterone acetate 10 mg thrice daily is given and treatment is usually continued for at least 90 days.

b. Levonorgestrel IUD - Mirena LNG IUS. LNG-IUS is recommended as a first line therapy for a woman with heavy menstrual bleeding in the absence of any structural or histological abnormality. "Can be used in all women as a first line of treatment of menorrhagia in place of oral medications. It is particularly useful for reproductive age women who also desire contraception" -William Gynae 1st/ed, p 188


5. GnRH agonist The subtherapeutic doses reduce the blood loss whereas in therapeu-tic doses produce amenorrhea. It is valuable as short-term use in severe DUB, particularly if the woman is infertile and wants pregnancy. The drugs are used subcutaneously or intranasally. It improves anemia, and is helpful when used before endometrial ablation. A varying degree of hypoestrogenic features may appear.


6. Danazol: Danazol is suitable in cases with recurrent symptoms and in patients waiting for hysterectomy. The dose varies from 200-400 mg daily in 4 divided doses continuously for 3 months. A smaller dose tends to minimize the blood loss and a higher dose produces amenorrhea. It reduces blood loss by 60 percent.


7. Mifepristone (RU 486): It is an anti-progesterone (19 nor- steroid). It inhibits ovulation and induces amenorrhea and reduces myoma size Surgical methods


8. Dilatation and Curettage can be used to control an acute episode of bleeding and is used for diagnostic purpose and not for therapeutic purpose as its effects are temporary. Ideally hysteroscopy and directed biopsy should be considered both for the purpose of diagnosis and therapy. Presently, dilatation and curettage should be used neither

as a diagnostic tool nor for the purpose of therapy.


9. Endometrial ablation

It is an alternative to hysterectomy in those reproductive age females who donot desire future pregnancy


10. Hysterectomy is generally not required in this age group but in older age group.

III Perimenopausall



Always rule out cancers first in

Peri menopausal age-M/C cause after

ruling out cancers is anovulatory


a. Never wait and watch Histo-pathological diagnosis

should be made


b. Do hysteroscopy and biopsy

along with papsmear and



c. Fractional currettage is

preferred to blind D and C.

In perimenopausal age- treatment is

• Progesterone - DMPA

 - Mirena

• Endometrial ablation

• Hysterectomy

In postmenopausal age-

Their is no role of hormonal therapy, do-

• Endometrial ablation

• Hysterectomy

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