Ovulatory Bleeding

Aka: Ovulatory Bleeding, Menorrhagia

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II. Pathophysiology

  1. Shortened or prolonged corpus luteum life span
  2. Abnormal relative ratio of Estrogen to Progesterone
    1. Usually due to low Estrogen levels

III. Risk Factors

  1. Increases with age

IV. Causes

  1. See Abnormal Uterine Bleeding Causes
  2. Uterine Fibroids (before Menopause)
  3. Endometrial Polyps
  4. Bleeding Disorders
    1. Von Willebrand Disease (present in 13% of women with Menorrhagia)
  5. Hypothyroidism
  6. Advanced liver disease

V. Symptoms

  1. Premenstrual Symptoms are present
  2. Menstrual Cycle intervals are normal (every 24 to 35 days)
  3. Quantifying Menstrual Bleeding amount
    1. Regular-absorbency tampons hold 6 to 9 grams (20 ml) of menstrual blood
    2. Super-absorbency tampons hold 9 to 12 grams (30 ml) of menstrual blood
    3. Heavy or Ultra Pads hold 30 to 50 ml of menstrual blood
    4. Menstrual Discs hold 60 to 80 ml of menstrual blood
    5. Menstrual Cups hold 20 to 35 ml of menstrual blood
    6. Menstrual underwear holds only 1-3 ml of menstrual blood
    7. DeLoughery (2024) BMJ Sex Reprod Health 50(1):21-6 +PMID: 37550075 [PubMed]
  4. Change in Amount of bleeding
    1. Menorrhagia
      1. Patient describes very heavy periods
      2. Change pad or tampon every 1-2 hours
      3. Blood clots >1 inch (2.5 cm)
      4. Patient passes over 80 ml blood per cycle
        1. The definition of 80 ml is no longer recommended
        2. Warner (2004) Am J Obstet Gynecol 190:1224-9 [PubMed]
    2. Prolonged bleeding
      1. Bleeding duration lasts 7 days or more per cycle

VI. Signs

  1. See Ovulation

VII. Labs: Initial

  1. Urine Pregnancy Test
  2. Complete Blood Count
  3. Thyroid Stimulating Hormone (TSH)
  4. Consider Serum Ferritin

VIII. Labs: Bleeding Disorder tests

  1. Indications
    1. Adolescents with Menorrhagia
    2. Family History of Bleeding Disorder
    3. Menses lasting 7 days or more with very heavy bleeding (flooding, associated Anemia)
    4. Excessive bleeding with other procedures (e.g. Tooth Extraction, Postpartum Hemorrhage)
    5. Women planning Hysterectomy for Menorrhagia
  2. Tests
    1. See Bleeding Disorder for protocol (esp. evaulation Von Willebrand's Disease)
    2. Complete Blood Count (CBC)
    3. ProTime (PT/INR)
    4. Partial Thromboplastic Time (PTT)

IX. Imaging

  1. Transvaginal Ultrasound
    1. Evaluate for uterine polyps and Uterine Fibroids
  2. Saline infusion Sonohysterography
    1. Indicated if Transvaginal Ultrasound is nondiagnostic

X. Evaluation

  1. See Abnormal Uterine Bleeding
  2. ACOG does not recommend routine TSH or Serum Prolactin testing for Menorrhagia
    1. Menorrhagia is most often due to fibroids or polyps
    2. Important to distinguish from annovulatory bleeding
      1. More often related to endocrine cause
  3. Consider Endometrial Cancer Screening
    1. Indicated if more than one Endometrial Cancer Risk Factors or refractory bleeding
    2. See Abnormal Uterine Bleeding
    3. See Endometrial Cancer Screening

XI. Management

  1. See Menorrhagia Management
  2. Uterine polyp
    1. Refer for hysteroscopic uterine polypectomy
  3. Uterine Fibroid
    1. See Uterine Fibroid for management options

XII. Complications

  1. Iron Deficiency Anemia
  2. Endometrial Hyperplasia and Endometrial Cancer are rarely associated with Ovulatory Bleeding (<1% risk)
    1. Consider Endometrial Cancer Screening if more than one Endometrial Cancer Risk Factors

XIII. References

  1. Nelson (1997), Fam Prac Recert 19(8):14
  2. Buchanan (2009) Am Fam Physician 80(10): 1075-88 [PubMed]
  3. Dilley (2001) Obstet Gynecol 97:630-6 [PubMed]
  4. Sweet (2012) Am Fam Physician 85(1): 35-43 [PubMed]

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Related Studies

Ontology: Menorrhagia (C0025323)

Definition (NCI_CTCAE) A disorder characterized by abnormally heavy vaginal bleeding during menses.
Definition (NCI_NCI-GLOSS) Abnormally heavy menstrual bleeding.
Definition (NCI) Heavy bleeding during regular menstruation.
Definition (MSH) Excessive uterine bleeding during MENSTRUATION.
Concepts Pathologic Function (T046)
MSH D008595
ICD10 N92.0
SnomedCT 123348000, 156038002, 63515003, 198418008, 289888001, 386692008
English Hypermenorrhea, Menorrhagia, MENORRHAGIA, MENSTRUAL FLOW EXCESSIVE, Heavy menstrual period, excessive menstrual bleeding, menorrhagia, excessive bleeding during period (symptom), excessive bleeding during period, heavy menstrual bleeding, menorrhagia (diagnosis), Hypermenorrhoea -RETIRED-, Menses regular with excessive bleeding, Bleeding menstrual heavy, Menstrual flow excessive, Excessive menstruation, Prolonged heavy periods, Menstruation increased, Menorrhagia NOS, Heavy periods NOS, Menorrhagia [Disease/Finding], heavy periods, heavy menstrual period, Menstruation;excessive, excessive menstrual flow, heavy prolonged periods, heavy period, heavy menstrual periods, Heavy menstrual period (finding), Hypermenorrhea (finding), Heavy periods, Hypermenorrhoea, Flooding during periods, Heavy period, Profuse menstrual flow, Menorrhagia (finding), Menstruation excessive, hypermenorrhea, excessive; menstruation, heavy; menstruation, menstruation; excessive, menstruation; heavy, Hypermenorrhea -RETIRED-, excessive menstruation, hypermenorrhoea
French MENORRAGIE, Règles abondantes et prolongées, Règles abondantes, Règles régulières avec saignements excessifs, Ecoulement menstruel excessif, Menstruation excessive, Menstruation augmentée, REGLES D'ABONDANCE EXCESSIVE, Ménorragie, Hyperménorrhée
Portuguese MENORRAGIA, Fluxo menstrual excessivo, Menstruação aumentada, Menstruações abundantes prolongadas, Menstruação regular com hemorragia excessiva, Hemorragia menstrual abundante, Menstruações abundantes, Menstruação excessiva, FLUXO MENSTRUAL EXCESSIVO, Hipermenorreia, Menorragia
Spanish MENORRAGIA, Menstruación regular con sangrado excesivo, Flujo menstrual excesivo, Menstruación excesiva, Sangrado menstrual abundante, Periodos abundantes, Periodos abundantes y prolongados, Menstruación aumentada, MENSTRUACION, FLUJO EXAGERADO, menstruación profusa, hipermenorrea - RETIRADO - (concepto no activo), hipermenorrea - RETIRADO -, hipermenorrea (hallazgo), hipermenorrea, excesivo sangrado menstrual, menorragia (hallazgo), menorragia, menstruación abundante, Menorragia, Hipermenorrea
German MENORRHAGIE, exzessive Menstruationsblutung, Menses regelmessig mit exzessiver Blutung, Menstruationsfluss exzessiv, Menstruationsblutung heftig, heftige Perioden, verlaengerte heftige Perioden, Menstruation vermehrt, MENSTRUATIONSBLUTUNG UEBERMAESSIG, Hypermenorrhoe, Menorrhagie
Dutch overmatige maandstonden, hevige menstruele bloeding, overvloedige menstruatie, hypermenorrhoea, regelmatige menses met overmatig bloedverlies, toegenomen menstruatie, verlengde en hevige ongesteldheid, overmatige menstruele bloeding, hevig; menstruatie, menstruatie; hevig, menstruatie; overmatig, overmatig; menstruatie, menorragie, Menorragie, Hypermenorroe
Italian Mestruazione eccessiva, Mestruazioni abbondanti prolungate, Mestruazioni abbondanti, Flusso mestruale eccessivo, Mestruazioni aumentate, Mestruazioni regolari con eccessivo sanguinamento, Ipermenorrea, Menorragia
Japanese 経血量過多, 遷延性月経過多, 出血過多を伴う規則月経, 過多または頻発月経, ｹﾞｯｹｲｶﾀ, ｹﾞｯｹｲｶﾀｼｮｳ, ｶﾀﾏﾀﾊﾋﾝﾊﾟﾂｹﾞｯｹｲ, ｼｭｯｹﾂｶﾀｦﾄﾓﾅｳｷｿｸｹﾞｯｹｲ, ｾﾝｴﾝｾｲｹﾞｯｹｲｶﾀ, ｹｲｹﾂﾘｮｳｶﾀ, 過多月経, 月経過多, 月経過多症
Swedish Mensblödning, riklig
Czech menoragie, Menoragie, Nadměrná menstruace, Nadměrné menstruační krvácení, Silné menstruační krvácení, Hypermenorea, Zvýšená intenzita menstruace, Pravidelné menses s nadměrným krvácením, Silné menstruace, Prodloužené silné menstruace
Finnish Menorragia
Russian MENORRAGIIA, GIPERMENOREIA, ГИПЕРМЕНОРЕЯ, МЕНОРРАГИЯ
Croatian HIPERMENOREJA, MENORAGIJA
Polish Miesiączkowanie nadmierne
Hungarian Fokozott menstruatio, Hypermenorrhea, túlzott mértékű menstruatio, Menorrhagia, bőséges menstruatiós vérzés, Prolongált bő menstruációk, Rendszeres menses fokozott vérzéssel, Nehéz időszakok, Túlzott mértékő menstruatiós áramlás, Hypermenorrhoea
Norwegian Kraftig menstruasjon, Menoragi, Hypermenoré
Derived from the NIH UMLS (Unified Medical Language System)

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