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Menorrhagia – An overview. By Dr Rukhsana Hussain ST1 17 th November 2009. Objectives. To increase awareness of menorrhagia, its causes and impact on individuals and society To cover key points in history-taking and examination

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menorrhagia an overview

Menorrhagia – An overview

By Dr Rukhsana Hussain ST1

17th November 2009

objectives
Objectives
  • To increase awareness of menorrhagia, its causes and impact on individuals and society
  • To cover key points in history-taking and examination
  • To increase awareness of medical and surgical treatments available as outlined by the NICE guidelines
menorrhagia definition
Menorrhagia - Definition

“Excessive menstrual blood loss which interferes with a woman’s physical, emotional, social and material quality of life and which can occur alone or in combination with other symptoms”(NICE guidelines 2007)

Objective blood loss >80ml no longer important in defining menorrhagia

impact of menorrhagia
Impact of menorrhagia
  • 1 in 20 women aged 30-49 years consults GP each year with menorrhagia
  • Many women will have days off work due to menorrhagia
  • 1 in 5 women in UK will have hysterectomy before age of 60 years
  • 50% of all women who have a hysterectomy for menorrhagia will have a normal uterus removed
causes of menorrhagia
Causes of menorrhagia
  • 4 main subtypes

1) Ovulatory

2) Anovulatory

3) Anatomic

4) Other causes

ovulatory menorrhagia
Ovulatory menorrhagia
  • “Primary” or “idiopathic” menorrhagia – treatments guided by probable causes
  • Characterized by heavy bleeding during regular cycles. Usually associated dysmenorrhoea and premenstrual symptoms
  • Probable causes
    • Abnormal prostaglandin synthesis
    • Increased intrauterine fibrinolysis
    • Acquired /congenital clotting disorders eg VWD
anovulatory menorrhagia
Anovulatory menorrhagia
  • Usually irregular periods, often heavy and frequently separated by long intervals. Usually minimal pain
  • Menorrhagia in adolescents usually anovulatory
  • Anovulatory cycles less common in 20-40 age group
anovulatory menorrhagia8
Anovulatory menorrhagia
  • Common in perimenopausal women
  • Intermittent ovulation and ovarian queiscence results in variability in LH/FSH and oestrogen causing erratic cycles
  • During this period follicles remaining in ovary are quite resistant to FSH – sometimes ovulation occurs after long follicular phase, other times it fails.
anovulatory menorrhagia9
Anovulatory menorrhagia
  • In delayed ovulation/anovulation endometrium is thickened by prolonged stimulation by proliferative levels of oestrogen and is eventually shed in a long and heavy period
  • Long term anovulation increases risk of endometrial hyperplasia
anovulatory menorrhagia10
Anovulatory menorrhagia
  • Causes include
    • Hyperprolactinaemia
    • Thyroid disease
    • Adrenal disease
    • Anorexia/Bulimia
    • Pituitary adenoma
    • Chronic illness
    • Stress
    • Drugs – eg. tricyclic antidepressants, steroids
anatomic menorrhagia
Anatomic menorrhagia
  • Commonly caused by endometrial polyps or submucosal fibroids

Polyp

other causes menorrhagia
Other causes menorrhagia
  • Cervicitis/endometritis
  • IUD
  • Hyperoestrogenism
  • Endometrial cancer
  • Coagulopathy
history key points
History – key points
  • Age at menarche
  • Onset and duration of period
  • Cycle – regular or irregular? Length?
  • Amount blood loss – clots? Flooding? Number sanitary towels? Social impact
  • Changes from previous bleeding patterns
  • Intermenstrual bleeding
  • Postcoital bleeding
  • Pelvic pain
  • Dyspareunia
history
History
  • Symptoms related to anaemia

- SOB/fatigue/dizziness

  • Symptoms of thyroid disease/systemic illness
  • PMH – Obstetric Hx, Fertility wishes
  • DH- Warfarin? Aspirin? Allergies
  • SH – Stress? Smoking? Alcohol intake?
  • FH – Bleeding disorders? Malignancies?
history15
History
  • Cover risk factors for Endometrial Cancer
    • Obesity
    • Age > 45
    • Nulliparity
    • PCOS
    • Tamoxifen
    • 1st degree relative with breast, colon or endometrial cancer
    • Personal hx breast/colon cancer
    • Unopposed oestrogen treatment
examination
Examination
  • General – pallor? Bruising? Signs of thyroid disease? BMI?
  • Abdominal examination – fibroid uterus?
  • Pelvic examination
investigations
Investigations
  • FBC – exclude anaemia
  • Cervical smear if due
  • If IMB/PCB vaginal swab for chlamydia screen
  • USS pelvis if indicated
  • Referral for hysteroscopy and endometrial biopsy – Persistent IMB, >45 years, treatment failure, ineffective treatment , risk factors endometrial cancer
  • NO value of TFT unless signs thyroid disease. NO value of hormone levels according to NICE guidelines
medical treatments first line
Medical treatments – First Line
  • Levonorgestrel-releasing intrauterine system

(MIRENA)

- Slowly releases progestogen, prevents proliferation of endometrium

  • Reduces menstrual loss by 86% in 3 months, and by 97% at 12 months
  • Effective contraceptive
  • Return to fertility after removal
medical treatments first line19
Medical treatments – First Line
  • Side effects Mirena coil

- progestagenic effects – breast tenderness, acne, headaches

- irregular bleeding at start may last for 6 mths

- functional ovarian cysts

Also, risk of uterine perforation at time of insertion

medical treatments second line
Medical treatments – Second line
  • Tranexamic acid
  • Mefenamic acid/NSAIDs
  • COCP
  • Can be used first line if Mirena not acceptable to patient
tranexamic acid
Tranexamic acid
  • Antifibrinolytic agent
  • Mean reduction blood loss nearly 50%
  • Dose 1-1.5g tds during menstruation only
  • May be combined with mefenamic acid esp if dysmenorrhoea prominent
  • Theoretically increased risk DVT but little evidence in studies
  • Suitable if patient wanting to conceive
  • Use for 3 cycles to determine effectiveness
mefenamic acid
Mefenamic acid
  • Reduces prostaglandin production
  • Indicated for menorrhagia and dysmenorrhoea
  • Mean reduction blood loss around 30%
  • Dose 500mg tds – taken during menstruation
  • Side effects – indigestion, diarrhoea, worsening asthma, peptic ulceration
slide23
COCP
  • Prevents proliferation of endometrium therefore reducing blood loss
  • Contraceptive
  • Side effects - headache, mood change, fluid retention,

risk of DVT, stroke

medical treatments third line
Medical treatments – Third line
  • Oral progestogen – norethisterone
    • Effective when given in high doses between day 5- 26 of cycle
    • Dose 5mg tds
  • Injected progestogen (Depo-provera)
    • Given every 3/12
    • After 1 year 50% women amenorrhoeic
    • Disadvantage of delayed return to fertility
medical treatments
Medical treatments
  • Gn-RH analogue injections
  • Stop production of oestrogen and progesterone inducing amenorrhoea
  • Side effects include menopausal- like symptoms
  • Risk of osteoporosis with longer than 6 month use
surgical radiological treatments
Surgical/radiological treatments
  • Endometrial ablation
  • Uterine artery embolisation
  • Myomectomy
  • Hysterectomy
endometrial ablation
Endometrial ablation
  • Indication – severe impact on quality of life + no desire to conceive + normal uterus (or small fibroids <3cm diameter)
  • Destroys womb lining
  • Risk of perforation during procedure
  • Possible side effects – vaginal discharge, increased period pain
uterine artery embolisation
Uterine artery embolisation
  • Indication – fibroids >3cm diameter, pressure symptoms, not wanting surgery, wants to remain fertile
  • Small particles injected into blood vessels supplying uterus , block supply to fibroids causing shrinkage
  • Short hospital stay – usually overnight
  • Side effects – persistent PV discharge, post embolisation syndrome – pain, nausea, vomiting, fever. Risk of haemorrhage
myomectomy
Myomectomy
  • Indication – fibroids > 3cm, severe impact on quality of life
  • Risks associated with surgery – adhesions, infection, perforation, haemorrhage
  • Recurrence of fibroids possible
hysterectomy
Hysterectomy
  • Indication – other treatments failed, no wish to remain fertile, patient request after fully informed, desire for amenorrhoea
  • Vaginal /abdominal as indicated
  • Major surgery – 4-5 days inpatient stay, risks of surgery
  • Longer recovery time- months although permanent solution for menorrhagia!
summary
Summary
  • Menorrhagia is a common problem
  • Mirena coil is offered as first line treatment and has reduced need for hysterectomies significantly
  • For women wanting to conceive in short term – tranexamic acid and mefenamic acid appropriate
  • For others COCP, norethisterone, Depo-provera can be effective
  • Surgical and radiological interventions available in secondary care setting
references
References
  • www.nice.org.uk – Heavy menstrual bleeding NICE 2007
  • www.doctors.net.uk
  • Oxford Handbook of Obstetrics and Gynaecology