MENORRHAGIA Flashcards
What is the definition of menorrhagia?
Excessive menstrual blood loss which interfered with a woman’s physicial, social, emotional or maternal quality of life which can occur alone or in combination with other sym,proms
It is defined in clinical settings as blood loss of >80ml and/or a duration of menstruation >7 days. This is not really used anymore as it’s highly subjective so we now focus more on the impact on QOL
Whats the normal volume of blood loss during menstruation?
25-80ml
Prevalence of menorrhagia in adolescent population?
37%
Causes of menorrhagia
• Uterine and ovarian pathologies
◦ Uterine fibroids
◦ Endometrial polyps
◦ Cancer of ovary, uterus, cervix of endometrium
◦ Endometriosis and adenomyosis
◦ Polycystic ovary syndrome
◦ Pelvic inflammatory disease
◦ Dysfunctional uterine bleeding (no identifiable cause - often occurs in young girls)
◦ Anovulatory cycles
• Systemic conditions
◦ Coagulation disorders e.g. VWD
◦ Hypothyroidism
◦ Diabetes mellitus
◦ Hyperprolactinaemia
◦ Liver or renal disease
• Meds
◦ Anticoagulants, antiplatelets, NSAIDs, COCP
◦ Intrauterine contraceptive device - particuarly copper coil
INvestigtaions for menorrhagia?
FBC- for IDA
Pregnancy test if reproductive age
Vaginal or cervical swab is ?infection
TFT is features of hypothyroidism
Test for coagulation disorders if had menstrual bleeding since menarche and have a personal or FHx
If history and exam suggests high risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis then investigate further:
Hysteroscopy for suspected fibroids, polyps, endometrial pathology
Pelvi USS for suspected large fibroids (palpable uterus through abdomen, pelvic mass)
Transvaginal USS for suspected adenomyosis (significant dysmenorrhea or bulky tender uterus on exam)
If history and exam suggest low risk then consider starting Tx without further investigations
How should you manage women with menorrhagia who does not require contraception and there is no underlying pathology?
Mefanamic acid 500mg tds (particuarly if dysmenorrhea as well) or tranexamic acid 1g tds - start on the first day of the period
(If no improvement try other drug whilst awaiting referral)
How should you manage women with menorrhagia who requires contraception and there is no underlying pathology?
First line: Intrauterine levonorgestrel system (Mirena coil)
Second line: COCP
Third line: long -acting progestogens
What is second generation endometrial ablation?
It involves passing a specifically designed balloon into the endometrial cavity and filling it with high-temperature fluid to burn the endometrial lining
It replaced first generation which involves a hysteroscopy and direct destruction of the endometrium. Second generation is safer and faster
used for menorrhagia Tx
How does the levonorgestrel intrauterine system work?
The Mirena coil releases a progestin hormone called levonorgestrel which helps to thin the endometrium and reduce the amount of menstrual bleeding
Moa tranexamic acid?
Blocks lysine binding sites on plasminogen to prevent plasmin formation
Plasmin cannot then bind fibrin and induce fibrinolysis which stabilises the clot and prevents haemorrhage
Side effects of tranexamic acid?
Diarrhoea
Nausea
Vomiting
What drug called is mefanamic acid?
NSAID
How do NSAIDs help in menorrhagia?
They inhibit cox1 and cox2 enzymes which decreases prostaglandin production = decreases intensity of uterine contractions and reduces bleeding
How can contraceptive pills help in menorrhagia/
They can regulate the menstrual cycle so that it is more predictable and often lightens the menstrual flow
They can thin the lining of the endometrium, stabilise hormone levels and reduce production of prostaglandins
What is uterine artery embolisation?
A minimally invasive procedure where a radiologist inserts a catheter into the femoral artery and, using real-time imaging, will guide it to the uterine arteries that supple blood o the fibroids. They then place tiny particles such as polyvinyl alcohol into these arteries which blocks the blood flow to the fibroids and causes them to shrink
What is a myomectomy?
Surgical removal of uterine fibroids
What is a hysterectomy?
Surgical removal of the uterus
What is the medical term for a fibroid?
A leiomyoma
What are fibroids?
Benign smooth muscle tumours of the uterus
A mixture of smooth muscle cells and fibroblasts
What are the different types of fibroids?
Subserosal - outer serosal surface of uterus and extend into peritoneal cavity so commonly asymptomatic
Intramural - develop within myometrium, as they grow they can distort the uterus shape so can cause menorrhagia or dysmenorrhoea by interfering with the constriction of blood vessels
Submucosal - inner mucosa surface of uterus and extend into uterine cavity. Even when relatively small they can cause significant menorrhagia, dysmenorrhoea or reduced fertility
Pedunculated - on a stalk
How common are fibroids?
Occur in 20% of white women and 50% of black women in later reproductive years
Risk factors for fibroids?
Increasing age - rare before puberty as fibroids are usually oestrogen-dependant. Peak at perimenopausal years and decline after
Early menarche - due to prolonged exposure to oestrogen
Nulliparity
Older age at first pregnancy - as they tend to enlarge during first trimester of pregnancy and then shrink post partum
Black and Asian women
FHx
Symptoms of fibroids?
May be asymptomatic
Menorrhagia which may result in IDA
Bulk-related symptoms e.g. lower abdominal cramps during menstruation, bloating, urinary symptms with large ones
Subfertility or infertility
What would you feel on abdominal and pelvic examination in a pt with uterine fibroids?
Firm enlarged irreguarly shaped non-tender uterus on pelvic exam (note the uterus can be up to 10 times its normal size)
Central irregular abdominal mass on abdo palpation
How do we diagnose uterine fibroids?
Transvaginal USS - well-defined, solid, concentric, hypoechoic masses that cause a variable amount of acoustic shadowing
How do we manage asymptomatic fibroids?
No treatmen but periodic review to monitor size and growth
How d we manage menorrhagia secondary to fibroids?
Levonorgestrel intrauterine system (note cannot be used if there is distortion of the uterus)
NSAIDs e.g. mefanamic acid
Tranexamic acid
COCP
Oral progestogen
Injectable progestogen
How do we treat fibroids to remove them indefinitely?
Medical - GnRH agonists such as goserelin may reduce the size of the fibroids but typically short term (<6 months) treatment due to SE
Surgical - myomectomy, hysteroscopic endometrial ablation, hysterectomy
Uterine artery embolisation
Side efefcts of GnRH agonists
Menopausal symptoms s - hot flushes, vaginal dryness
Loss of bone mineral density
Prognosis of fibroids?
Generally regress after menopause due to drop in oestrogen
Complications of fibroids?
Subfertility or infertility as they can distort the uterine cavity and interfere with implantation
IDA
Complications during pregnancy - miscarriage, red degeneration, foetal malpresentation, preterm
Compression of adjacent organs - recurrent UTIs, urinary retention, hydronephrosis - rare
Torsion of a pedunculated fibroid - rare
Haemoperitoneum - rare
What is red degeneration of a fibroid?
Also called fibroid vascular infarction
Ischaemic, infarction and necrosis of the fibroid due to disrupted blood supply
More likely in larger fibroids i.e. >5cm during the 2nd and 3rd trimester or pregnancy as the fibroid rapidly enlarges and outgrows its blood supply
How does red degeneration of a fibroid present?
Severe abdominal pain, low grade fever, tachycardia and often vomiting
What is endometriosis?
A common condition characterised by growth of endometrium-like tissue outside the uterus
Where is endometriosis most typically found?
In the pelvis: ovaries, uterosacral ligaments, pouch of Douglas, rectum, sigmoid colon, bladder and distal ureter
Extrapelvic deposits are rare
Cause of endometriosis
Exact cause not known. Several theories:
Retrograde menstruation - endometrial cells throw backwards from uterine cavity through fallopian tubes and implant on pelvic organs where they seed and grow during menstruation
Lymphatic or circulatory dissemination
Generic predisposition
Metaplasia
Immune dysfunction
Certain environmental toxins
How common is endometriosis?
10% of women of reproductive age have a degree of it
Prevalence of endometriosis in women with infertility?
30-50%
