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Menorrhagia

Menorrhagia . Samadhi Reid NPT VTS September 2008. Definition.

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Menorrhagia

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  1. Menorrhagia Samadhi Reid NPT VTS September 2008

  2. Definition Excessive menstrual blood loss, which interferes with a woman’s physical, social, emotional and/or material quality of life. Whether menstrual blood loss is a problem should be determined not by measuring blood loss but by the woman herself NICE 2007

  3. Age; if > 45 need to think of endometrial carcinoma or atypical hyperplasia Menstrual Hx; • Establish impact on QOL • Duration of symptom – if since menarche, consider bleeding disorder • Is the cycle regular and heavy or • Is there IMB, polymenorrhoea or post coital bleeding

  4. If there is abnormal bleeding • Need to explore smear Hx • PV Discharge, Sexual Hx • Is there pelvic pain/ dyspareunia • Contraception - COCP, Implant, Cu coil Contraception; Is this needed? Obstetric Hx; Relevant if a coil is being considered, Is the family complete? Check for symptoms of hypothyroidism, PMH and DH

  5. Examination and Investigations • If the Hx suggest no structural or histological abnormality Rx can be started without physical examination or other Ix, in the primary care setting (NICE 07) • Swabs may be indicated •  FBC •  Routine TFT, clotting • USS - If structural or histological abnormality is suspected

  6. Management If no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity (NICE 07) • LNG-IUS provided long-term use is anticipated 2) Tranexamic acid (1g TDS) or NSAIDs (Mefenamic acid 500mg QDS) or COCP 3) Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle or injected long-acting progestogens

  7. Oxford General Practice Library- Women’s Health, Salder C at el, 2008, Oxford University press

  8. Consider Referral • Endometrial biopsy - treatment failure, if >45 yrs, persistent IMB • Further Ix - Hysteroscopy (when USS results are inconclusive) • Palpable fibroids, or uterine length > 12 cm on USS

  9. Surgical Treatment If fertility is to be preserved; • Uterine artery embolisation as first line Rx • Myomectomy If fertility is not an issue; • Endometrial ablation is the first choice • Hysterectomy, Vaginal preferred to Abdominal

  10. Case 1 • 42 yr, presented in Dec 07 with HMB • Regular cycle 28-32/7, prolonged bleeding, lasting 2/52 • O/E NAD, Refused coil, Rx with Tranexamic + Mef acid • Bleeding slightly better; continued to c/o tiredness • Hb = 6, USS + Referral • USS - ? Endometrial thickening • Hysteroscopy - Polyp, was Rx, benign

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