اغلب زنان در دورهای از زندگی خود، خونریزی شدید قاعدگی را تجربه میکنند. بعضی از آنها تقریباً در تمامی دورهها خونریزی شدید دارند. پزشکان اصطلاحاً به این خونریزی شدید یا طولانی، «منوراژی» (به انگلیسی: Menorrhagia) (پُردشتانی) یا «هایپرمنوره» میگویند.
با وجود اینکه خونریزی شدید ماهانه در میان زنان در پیش از یائسگی شایع است، تنها درصد کمی از زنان آنقدر زیاد خون دفع میکنند که در حد «منوراژی» باشد. برای اینکه خونریزی ماهانه به حد منوراژی برسد باید حداقل بعضی از علایم زیر را ایجاد کند:
درمان این مشکل بر تشخیص علت استوار است. درمواردی که علت مشخصی یافت نشود استفاده از قرصهای جلوگیری از حاملگی خوراکی و آنتی آندروژنها مانند دانازول مفیدند. در خانمهای سنین بالا میتوان برداشتن رحم را مطرح کرد. همچنین با استفاده از عمل اندومتریال ابلیشن میتوان در منوراژیهای خوشخیم از خارج کردن رحم جلوگیری کرد. این عمل توسط بالن آب گرم (کاواترم) در مدت زمان ۱۰ دقیقه با فشار ۲۳۰–۲۴۰ میلیمتر جیوه و دمای ۸۰ درجه دیواره داخلی رحم (اندومتر) ابلیت میشود. این عمل در ایران در حال انجام است.
Abnormal uterine bleeding can be caused by structural abnormalities in the reproductive tract, anovulation, bleeding disorders, hormone issues (such as hypothyroidism) or cancer of the reproductive tract. Initial evaluation aims at figuring out pregnancy status, menopausal status, and the source of bleeding.
Treatment depends on the cause, severity, and interference with quality of life. Initial treatment often involve contraceptive pills. Surgery can be an effective second line treatment for those women whose symptoms are not well-controlled. Approximately 53 in 1000 women are affected by AUB.
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. Menorrhagia is defined as total menstrual flow >80ml per cycle, or soaking a pad/tampon every 2 hours or less. Deviations in terms of frequency of menses, duration of menses, or volume of menses qualifies as abnormal uterine bleeding. Bleeding in between menses is also abnormal uterine bleeding and thus requires further evaluation.
Complications of Menorrhagia could also be the initial symptoms. Excessive bleeding can lead to anemia which presents as fatigue, shortness of breath, and weakness. Anemia can be diagnosed with a blood test.
Usually no causative abnormality can be identified and treatment is directed at the symptom, rather than a specific mechanism. However, there are known causes of abnormal uterine bleeding that need to be ruled out. Most common causes based on the nature of bleeding is listed below followed by the rare causes of bleeding (i.e. disorders of coagulation).
Diagnosis is largely achieved by obtaining a complete medical history followed by physical exam and ultrasound. If need be, laboratory tests or hysteroscopy may be used. The following are a list of diagnostic procedures that medical professionals may use to identify the cause of the abnormal uterine bleeding.
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 due to bleeding then iron tablets may be used to help restore normal hemoglobin levels.
The condition is often treated with hormones, particularly as abnormal 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.
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.
These have been ranked by the UK's National Institute for Health and Clinical Excellence:
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.