T he origins o f m enorrhagia com e from the Greek men, m eaning m onth and
rhegyai, m eaning to burst forth. M enorrhagia is excessive or irregular bleeding
(blood loss over 80 m l monthly) from the vagina, a com m on m enstrual disorder (L ew is & C ham berlain, 1990) w hich accounts for nearly one m illion G P
consultations a year in the United K ingdom (Parke-D avis, 1983). A M O R I survey
show ed that 31% o f fertile w om en in the U K com plain o f heavy m enstrual
bleeding. lie s & Gath (1989) suggest that m enorrhagia is ‘one o f the com m onest
presenting com plaints am ongst w om en approaching the m enopause.’ T he m ean
age at m enopause is about 50 years (Coope, 1993) but it can occur betw een the
ages o f 45 to 55. In a survey o f a gynaecological outpatient clinic, B allinger
(1977) reported that 39% o f patients betw een 40 to 44, and 62% o f patients aged
betw een 45-49 com plained o f long or heavy m enstrual blood loss.
T here are a num ber o f reasons for the occurrence o f m enorrhagia. It could he
Menstruation, Menstrual Problems and Hysterectomy
22
endom etriosis, pelvic inflam m atory disease (R ees, 1989) and intrauterine
contraceptive devices (Lewis & C ham berlain, 1990). Psychosom atic disturbances
often account for excessive or frequent m enstrual bleeding w hich often subsides
w hen the problem disappears - pituitary function is responsible for this
irregularity (Lew is & C ham berlain, 1990). W hen no evident pathology can be
established, these cases are referred to as dysfunctional uterine bleeding (N ovak
& W oodruff, 1974).
O f m ajor concern to gynaecologists and psychologists is that 60% o f
hysterectom ies in England and W ales are for m enorrhagia (M cPherson, 1983).
O nly 40% o f those undergoing hysterectom y for this problem actually have
objective m enorrhagia (Fraser, M cC arron, M arkham , R esta & W atts, 1986).
O ne o f the m ain problem s concerning m enorrhagia is that it is a subjective
com plaint w hich is seldom confirm ed clinically (Fraser, M cC arron, M arkham ,
R esta & W atts, 1986). For exam ple, in gynaecological practice, the p atien t’s self
statem ent o f her heavy m enstrual blood loss is enough for initiating m edical or
surgical treatm ent (C him bira, A nderson, & Turnbull, 1980). Since treatm ent for
m enorrhagia frequently results in hysterectom y, serious considerations should be
given to reappraising the assessm ent o f this com plaint. This is particularly
significant w hen studies (e.g. H allberg, H agdahl, N ilsson & R ybo, 1966) have
reported that w om en often m ake poor judgem ents o f the volum e o f their
m enstrual blood loss. H allberg et al (1966) reported that 40% o f w om en with
m enstrual blood loss exceeding 80 ml regarded their m enstruation only
m oderately heavy or light, but 14% o f those w ith a m easured loss o f less than
im portant to understand w hy w om ens’ perceptions o f m enstrual blood loss are
often inaccurate. Fraser, M cC arron & M arkham (1985) report that m any
w om en lose their m enstrual discharge in sm all gushes w hich lead to ^accidents’,
soiling or soaking o f clothes, and that the total volum e o f m enstrual discharge is
m ore than double the blood content,’ (cited in Fraser, 1989).
O bjective m easurem ent o f m enstrual blood loss (MBL) is based on results from
a Sw edish population study with 476 w om en (H allberg, 1966) and 348 w om en in
N orthum berland (Cole, B illew icz & Thom son, 1971). This technique uses the
alkaline m ethod o f H allberg & N ilsson (1964) - w here blood is extracted from
sanitary tow els using a sodium hydroxide (N aO H ) solution, then its optical
density is m easured and com pared with a venous blood control. O bjective
m easurem ent o f blood loss has a skew ed distribution w ith a m ean o f 35 m l and
the 90th percentile o f 80 m l (Rees, 1989). M enstrual blood loss exceeding 80 ml
per m onth causes iron deficiency anaem ia in 20% to 25% o f fertile fem ales in the
U nited K ingdom (Sm ith, 1985).
Several researchers (G ranleese, 1990; Fraser, M cC arron & M arkham , 1984;
C him bira, A nderson & Turnbull, 1980) have that found significant discrepancies
exist betw een w om en ’s subjective estim ation o f their M BL and an objective
m easurem ent o f it. Som e researchers have also included other factors w ith these
m easurem ents. For exam ple, C him bira et al (1980) exam ined the relation
betw een m easured m enstrual blood loss and p atien t’s subjective assessm ent o f
loss (during tw o consecutive m enstrual periods), duration o f b leeding, num ber o f
sanitary tow els used, uterine weight and endom etrial surface area. In 44% o f the
Menstruation, Menstrual Problems and Hysterectomy
24
m enorrhagia, the uterus was w eighed and the endom etrial surface area m easured.
T here was no evidence to support the notion that m enorrhagia is associated w ith
a large uterus or large endom etrial surface. Interestingly, C him hira et al (1980)
suggest that even if w om en w ere inform ed that their M B L was norm al, they m ay
not believe it. How ever, this assertion was not tested.
G ranleese (1990) argued that d ia g n o sis o f m enorrhagia should not he m ade on
the self-statem ent o f patients alone nor on reported m enstrual sym ptom atology
but only on the basis o f objective m easurem ent o f m enstrual blood lo ss’ (MBL).
T here are nonetheless problem s with this procedure. She reported that both
tam pons and sanitary towels were found to have a m ean recovery rate ranging
from 80.5 to 86.5% and 81.3 to 84.4% , respectively. How these figures are
arrived at is questionable. For exam ple, w om en notoriously lose their tam pons
and sanitary tow els down the toilet. Furtherm ore, even w hen ‘going to the to ilet’
w om en lose m enstrual blood (including blood clots). R em em bering to collect
soiled sanitary protection in public conveniences and keep them on o n e ’s person
poses obvious problem s. Therefore how accurate is objective M B L l C ertainly
objective M BL can be an im portant factor in identifying m enorrhagia in m edical
term s, but the m ethods presently used for m easuring it are inadequate. O ther
factors have to be considered when exam ining w om en presenting w ith
m enorrhagia.
M any studies investigating patients presenting with m enorrhagia (e.g. G ranleese,
1990) fail to establish w hether the respondents were using, or if they have ever
used a contraceptive device. The ‘p ill’ is know n to lessen m enstrual blood loss
intrauterine device often increases m enstrual blood loss (Lewis & C ham berlain,
1990). W om en presenting w ith m enorrhagia could have been on the ‘p ill’ for
several years. W hen these patients then experience *normaV m enstruation after
stopping the pill, it m ay appear ‘abnormaV to them since their m enstrual blood
loss could have increased in quantity. Since m enstrual blood loss varies from
w om an to w om an, norm ality (o f menstrual blood loss) could he interpreted as: an
in d ividu al’s experience o f m enstruation and what is acceptable or unacceptable
to her. In other w ords, if it im pinged on her quality o f life, then it could he
perceived unacceptable. Perhaps this m ight he a m ore valid basis for m edical
intervention than objective M BL.