Menorrhagia Flashcards
What is menorrhagia?
-heavy menstrual bleeding
What is seen as excessive menstrual bleeding (menorrhagia)?
- excessive menstrual blood loss involves >80ml loss of blood
- normal loss would be 40ml
- volume of blood loss is rarely measured in practice
What is the diagnosis of menorrhagia based on?
based on symptoms such as:
- changing pads every 1-2 hours
- bleeding lasting more than 7 days and passing large clots
- diagnosis can be made based on self report of very heavy periods
What are causes of menorrhagia?
- dysfunctional uterine bleeding (no identifiable cause)
- extremes of reproductive age
- fibroids
- endometriosis and adenomyosis
- PID (infection)
- contraceptives, especially copper coil
- anticoags
- bleeding disorders eg VWD
- endocrine disorders (diabetes and hypothyroid)
- connective tissue disorders
- endometrial hyperplasia or cancer
- PCOS
What are key things to ask about in gynae history?
- age at menarche
- cycle length, days menstruating and variation
- intermenstrual bleeding and post coital bleeding
- contraceptive history
- sexual history
- possibility of pregnancy
- plans for future pregnancies
- cervical screening history
- migraines
- PMH and DH
- FH and SH
What are the investigations for menorrhagia?
- pelvic examination with a speculum and bimanual exam–>mainly to assess for fibroids, ascites and cancers
- FBC to look for iron deficiency anaemia
- Outpatient hysteroscopy
- pelvic and transvaginal US
What other additional tests might be considered for menorrhagia?
- swabs if evidence of infection
- coagulation screen if FH of clotting disorders or periods always been heavy since menarche
- ferritin if anaemic
- TFT if features of hypothyroidsm
What is the first thing to do in the management of menorrhagia?
- exclude underlying pathology such as anaemia, fibroids, bleeding disorders and cancer
- if causes identified these should be managed initially
- then establish whether contraception is required or accepted by the patient
What is the management of menorrhagia when contraception is not accepted by the patient?
treatment used during menstruation for symptomatic relief:
- Tranexamic acid if no pain (antifibrinolytic -reduced bleeding)
- Mefenamic acid when there is pain (NSAID - reduced bleeding and pain)
What is the management of menorrhagia when contraception is accepted by the patient?
- Mirena coil (first line)
- Combined OCP
- Cyclical oral progestogens such as norethisterone
What are the options if medical management has failed for menorrhagia?
- endometrial ablation
- hysterectomy
A 24 year old lady attends gynaecology clinic for management of her heavy menstrual bleeding. She has tried using tranexamic acid, however her periods are still too heavy. She does not experience painful periods.
She has had a transvaginal ultrasound and a full panel of blood tests including FBC, coagulation and thyroid function. All of these investigations have come back normal.
What is the most appropriate first-line management for this lady’s heavy menstrual bleeding?
A. POP
B. Mirena IUS
C. COCP
D. Mefanamic acid
E. Copper IUD
B. Mirena IUS
-levornogestrel is released into the endometrium which reduces proliferation and bleeding. Mirena has fewer side effects than COCP due to its local action.
What are some causes of menorrhagia (mnemonic)?
PALM COIENS (local)
-Polyp
-Adenomyosis
-Leiomyoma – a fibroid;
-Malignancy eg endometrial cancer
-Coagulopathy
-Ovulatory dysfunction
-Endometrial eg endometrosis
-Iatrogenic
-not otherwise classified
systemic:
-hypothyroidism
-obesity
-liver and kidney disease
-bleeding disorders
When should TVUSS be done?
-Possible large fibroids (palpable pelvic mass)
-Possible adenomyosis (associated pelvic pain or tenderness on examination)
-Examination is difficult to interpret (e.g. obesity)
-Hysteroscopy is declined
Investigations:
Bedside:
-speculum
-bimanual
-pregnancy test
Bloods:
-FBC (Hb), haematinics: ferritin, TFTs, coagulation studies, LFTs, Us &Es
Imaging:
-Outpatient hysteroscopy should be arranged if there is:
-Pelvic and transvaginal ultrasound should be arranged if the is:
