Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause



      Normal menstrual periods last 3–6 days and involve blood loss of up to 80 ml. Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80 ml. The prevalence of abnormal uterine bleeding (AUB) is estimated at 11–13% in the general population and increases with age, reaching 24% in those aged 36–40 years.


      A blood count for red cells + platelets to test for anemia is recommended on a first-line basis for women consulting for AUB whose history and/or bleeding score justify it. A pregnancy test by an hCG assay should be ordered. A speculum examination and Pap smear, according to the French High Health Authority guidelines should be performed early on to rule out any cervical disease. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of AUB. Hysteroscopy or hysterosonography can be suggested as a second-line procedure. MRI is not recommended as a first-line procedure.


      In idiopathic AUB, the first-line treatment is medical, with efficacy ranked as follows: levonorgestrel IUD, tranexamic acid, oral contraceptives, either estrogens and progestins or synthetic progestins only, 21 days a month, or NSAIDs. When hormone treatment is contraindicated or immediate pregnancy is desired, tranexamic acid is indicated. Iron must be included for patients with iron-deficiency anemia. For women who do not wish to become pregnant in the future and who have idiopathic AUB, the long-term efficacy of conservative surgical treatment is greater than that of oral medical treatment. Placement of a levonorgestrel IUD (or administration of tranexamic acid by default) is recommended for women with idiopathic AUB. If this fails, a conservative surgical technique must be proposed; the choices include second-generation endometrial ablation techniques (thermal balloon, microwave, radiofrequency), or, if necessary, first-generation techniques (endometrectomy, roller-ball). A first-line hysterectomy is not recommended in this context. Should a hysterectomy be selected for functional bleeding, it should be performed by the vaginal or laparoscopic routes.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


        • Janssen C.
        • Scholten P.
        • Heintz A.
        A simple visual assessment technique to discriminate between menorrhagia and normal menstrual blood loss.
        Obstet Gynecol. 1995; 85: 977-982
        • Sramek A.
        • Eikenboom J.
        • Briët E.
        • Vandenbroucke J.
        • Rosendaal F.
        Usefulness of patient interview in bleeding disorders.
        Arch Intern Med. 1995; 156: 1475
        • Drews C.
        • Dilley A.
        • Lally C.
        • Beckman M.
        • Evatt B.
        Screening questions to identify women with von Willebrand disease.
        J Am Med Womens Assoc. 2002; 57: 217-218
        • Philipp C.
        • Faiz A.
        • Dowling N.
        • et al.
        Development of a screening tool for identifying women with menorrhagia for hemostatic evaluation.
        Am J Obstet Gynecol. 2008; 198 (163.el–8)
        • Wilansky D.
        • Greisman B.
        Early hypothyroidism in patients with menorrhagia.
        Am J Obstet Gynecol. 1989; 160: 673-677
        • Squizzato A.
        • Romulaldi E.
        • Büller H.
        • Gerdes V.
        Thyroid dysfunction and effects on coagulation and fibrinolysis: a systematic review.
        J Clin Endocrinol Metab. 2007; 92: 2415-2420
        • Janssen C.
        • Scholten P.
        • Heintz A.
        A simple visual assessment technique to discriminate between menorrhagia and normal menstrual loss.
        Obstet Gynecol. 1995; 85: 977-982
        • Goddard A.
        • mcIntyre A.
        • Scott B.
        Guidelines for the management of iron deficiency anaemia.
        Br Soc Gastroenterol Gut. 2000; 46: IV1-IV5
        • Nichols W.
        • Hultin M.
        • James A.
        • et al.
        Von Willebrand disease (VWD) evidence-based diagnosis and management guidelines, the National Heart, Lung and Blood Institute (NHLBI) Expert Panel report (USA).
        Haemophilia. 2008; 14: 171-232
        • Haynes P.
        • Anderson A.
        • Turnbull A.
        Patterns of menstrual blood loss in menorrhagia.
        Res Clin Forums. 1979; 1: 73-78
        • Eldred J.
        • Thomas E.
        Pituitary and ovarian hormone levels in unexplained menorrhagia.
        Obstet Gynecol. 1994; 84: 775-778
        • Group REASPCW
        Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic syndrome (PCOS).
        Hum Reprod. 2004; 19: 41-47
        • Farquhar C.
        • Lethaby A.
        • Sowter M.
        • Verry J.
        • Barannyai J.
        An evaluation of risk factors for endometrial hyperplasia in premenopausal women with abnormal menstrual bleeding.
        Am J Obstet Gynecol. 1999; 181: 525-529
        • Ash S.
        • Farrell S.
        • Flowerdew G.
        Endometrial biopsy in DUB.
        J Reprod Med. 1996; 41: 892-896
        • Metzger U.
        • Bernard J.
        • Camatte S.
        • et al.
        Sono-guided endometrial biopsy: comparison with hysteroscopy biopsy. Sono-guided endometrial biopsy using the Bernard catheter had no impact on assessment by sonography.
        Gynecol Obstet Invest. 2004; 58: 26-31
        • Leone F.
        • Carsana L.
        • Lanzani C.
        • Vago G.
        • Ferrazzi E.
        Sonohysterographic endometrial sampling and hysteroscopic endometrial biopsy: a comparative study.
        Obstet Gynecol. 2007; 29: 443-448
        • Gimpelson R.J.
        • Rappold H.O.
        A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases.
        Am J Obstet Gynecol. 1988; 158: 489-492
        • Ben-Baruch G.
        • Seidman D.S.
        • Schiff E.
        • Moran O.
        • Menczer J.
        Outpatient endometrial sampling with the Pipelle curette.
        Gynecol Obstet Invest. 1994; 37: 260-262
        • Bain C.
        • Parkin D.
        • Cooper K.
        Is outpatient diagnostic hysteroscopy more useful than endometrial biopsy alone for the investigation of abnormal uterine bleeding in unselected premenopausal women? A randomised comparison.
        BJOG. 2002; 109: 805-811
        • Farquhar C.
        • Ekeroma A.
        • Furness S.
        • Arroll B.
        A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women.
        Acta Obstet Gynecol Scand. 2003; 82: 493-504
        • Dueholm M.
        • Lundorf E.
        • Olesen F.
        Imaging techniques for evaluation of the uterine cavity and endometrium in premenopausal patients before minimally invasive surgery.
        Obstet Gynecol Surv. 2002; 57: 388-403
        • Clark T.J.
        • Voit D.
        • Gupta J.K.
        • Hyde C.
        • Song F.
        • Khan K.S.
        Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review.
        JAMA. 2002 Oct; 288: 1610-1621
        • Tamai K.
        • Koyama T.
        • Saga T.
        • et al.
        Diffusion-weighted MR imaging of uterine endometrial cancer.
        J Magn Reson Imaging. 2007; 26: 682-687
        • Crescini C.
        • Artuso A.
        • Repetti F.
        • et al.
        Hysteroscopic diagnosis in patients with abnormal uterine hemorrhage and previous endometrial curettage.
        Miner Ginecol. 1992; 44: 233-235
        • Lethaby A.E.
        • Cooke I.
        • Rees M.
        Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding.
        Cochrane Database Syst Rev. 2005; 19 (CD002126)
        • Stewart A.
        • Cummins C.
        • Gold L.
        • Jordan R.
        • Phillips W.
        The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review.
        BJOG. 2001; 108: 74-86
        • NICE
        Heavy menstrual bleeding.
        R Coll Obstet Gynaecol. 2007;
        • Lethaby A.
        • Irvine G.
        • Cameron I.
        Cyclical progestogens for heavy menstrual bleeding.
        Cochrane Database Syst Rev. 2008; 23 (CD001016)
        • Irvine G.A.
        • Campbell-Brown M.B.
        • Lumsden M.A.
        • Heikkila A.
        • Walker J.J.
        • Cameron I.T.
        Randomised comparative trial of the levonorgestrel intrauterine system and norethisterone for treatment of idiopathic menorrhagia.
        Br J Obstet Gynaecol. 1998; 105: 592-598
        • Beaumont H.
        • Augood C.
        • Duckitt K.
        • Lethaby A.
        Danazol for heavy menstrual bleeding.
        Cochrane Database Syst Rev. 2007; 18 (CD001017)
        • Coulter A.
        • Kelland J.
        • Peto V.
        • Rees M.C.
        Treating menorrhagia in primary care. An overview of drug trials and a survey of prescribing practice.
        Int J Technol Assess Health Care. 1995; 11: 456-471
        • Preston J.T.
        • Cameron I.T.
        • Adams E.J.
        • Smith S.K.
        Comparative study of tranexamic acid and norethisterone in the treatment of ovulatory menorrhagia.
        Br J Obstet Gynaecol. 1995; 102: 401-406
        • Lethaby A.
        • Augood C.
        • Duckitt K.
        • Farquhar C.
        Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding.
        Cochrane Database Syst Rev. 2007; 17 (CD000400)
        • Agorastos T.
        • Bontis J.
        • Vakiani A.
        • Vavilis D.
        • Constantinidis T.
        Treatment of endometrial hyperplasias with gonadotropin-releasing hormone agonists: pathological, clinical, morphometric, and DNA-cytometric data.
        Gynecol Oncol. 1997; 65: 102-114
        • Nathani F.
        • Clark T.J.
        Uterine polypectomy in the management of abnormal uterine bleeding: a systematic review.
        J Minim Invasive Gynecol. 2006; 13: 260-268
        • Henriquez D.D.
        • van Dongen H.
        • Wolterbeek R.
        • Jansen F.W.
        Polypectomy in premenopausal women with abnormal uterine bleeding: effectiveness of hysteroscopic removal.
        J Minim Invasive Gynecol. 2007; 14: 59-63
        • Grigorieva V.
        • Chen-Mok M.
        • Tarasova M.
        • Mikhailov A.
        Use of a levonorgestrel-releasing intrauterine system to treat bleeding related to uterine leiomyomas.
        Fertil Steril. 2003; 79: 1194-1198
        • Parker W.H.
        Uterine myomas: management.
        Fertil Steril. 2007; 88: 255-271
        • Lethaby A.
        • Vollenhoven B.
        • Sowter M.
        Efficacy of pre-operative gonadotrophin hormone releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy: a systematic review.
        BJOG. 2002; 109: 1097-1108
        • Somigliana E.
        • Vercellini P.
        • Daguati R.
        • Pasin R.
        • De Giorgi O.
        • Crosignani P.G.
        Fibroids and female reproduction: a critical analysis of the evidence.
        Hum Reprod Update. 2007; 13: 465-476
        • Chapron C.
        • Fernandez B.
        • Fauconnier A.
        • Dubuisson J.B.
        Indications and modalities of conservative surgical treatment of interstitial and sub-serous myomas.
        J Gynecol Obstet Biol Reprod (Paris). 1999; 28: 732-737
        • Goodwin S.C.
        • Spies J.B.
        • Worthington-Kirsch R.
        • et al.
        Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry.
        Obstet Gynecol. 2008; 111: 22-33
        • Mara M.
        • Fucikova Z.
        • Maskova J.
        • Kuzel D.
        • Haakova L.
        Uterine fibroid embolization versus myomectomy in women wishing to preserve fertility: preliminary results of a randomized controlled trial.
        Eur J Obstet Gynecol Reprod Biol. 2006; 126: 226-233
        • Mara M.
        • Maskova J.
        • Fucikova Z.
        • Kuzel D.
        • Belsan T.
        • Sosna O.
        Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy.
        Cardiovasc Intervent Radiol. 2008; 31: 73-85
        • Pron G.
        • Mocarski E.
        • Bennett J.
        • Vilos G.
        • Common A.
        • Vanderburgh L.
        Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial.
        Obstet Gynecol. 2005; 105: 67-76
        • Fernandez H.
        • Donnadieu A.C.
        J Gynecol Obstet Biol Reprod (Paris). 2007; 36: 179-185
        • Marret H.
        • Cottier J.P.
        • Alonso A.M.
        • Giraudeau B.
        • Body G.
        • Herbreteau D.
        Predictive factors for fibroids recurrence after uterine artery embolisation.
        BJOG. 2005; 112: 461-465
        • Cho S.
        • Nam A.
        • Kim H.
        • et al.
        Clinical effects of the levonorgestrel-releasing intrauterine device in patients with adenomyosis.
        Am J Obstet Gynecol. 2008; 198: 373e1-17
        • Cooper K.G.
        • Parkin D.E.
        • Garratt A.M.
        • Grant A.M.
        A randomised comparison of medical and hysteroscopic management in women consulting a gynaecologist for treatment of heavy menstrual loss.
        Br J Obstet Gynaecol. 1997; 104: 1360-1366
        • Marjoribanks J.
        • Lethaby A.
        • Farquhar C.
        Surgery versus medical therapy for heavy menstrual bleeding.
        Cochrane Database Syst Rev. 2006; 19 (CD003855)
        • Lethaby A.
        • Hickey M.
        • Garry R.
        Endometrial destruction techniques for heavy menstrual bleeding.
        Cochrane Database Syst Rev. 2005; 19 (CD001501)
        • Kuppermann M.
        • Varner R.E.
        • Summitt Jr., R.L.
        • et al.
        Effect of hysterectomy vs medical treatment on health-related quality of life and sexual functioning: the medicine or surgery (Ms) randomized trial.
        JAMA. 2004; 291: 1447-1455
        • Lethaby A.
        • Shepperd S.
        • Cooke I.
        • Farquhar C.
        Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding.
        Cochrane Database Syst Rev. 2000; 2 (CD000329)
        • Dickersin K.
        • Munro M.G.
        • Clark M.
        • et al.
        Hysterectomy compared with endometrial ablation for dysfunctional uterine bleeding: a randomized controlled trial.
        Obstet Gynecol. 2007; 110: 1279-1289
        • Hirst A.
        • Dutton S.
        • Wu O.
        • et al.
        A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study.
        Health Technol Assess. 2008; 12: 1-248
        • Nilsson L.
        • Rybo G.
        Treatment of menorrhagia.
        Am J Obstet Gynecol. 1971; 110: 713-720
        • Claessens E.A.
        • Cowell C.A.
        Acute adolescent menorrhagia.
        Am J Obstet Gynecol. 1981; 139: 277-280