1.

Definition of menorrhagia
Menorrhagia is the medical term for menstrual periods with abnormally heavy or prolonged
bleeding. HMB is defined as a blood loss of greater than 80 mL per period. In reality,
methods to quantify menstrual blood loss are both inaccurate (poor correlation with
haemoglobin level) and impractical and so a clinical diagnosis based on the patients own
perception of blood loss is preferred.
2. What is the normal menstrual flow and menstrual cycle

3. Possible causes of menorrhagia

Aetiology
Fibroids (Figure 5.1)
Endometrial polyps (Figure 5.2)
Coagulation disorders, e.g. von Willebrands disease
Pelvic inflammatory disease (PID)
Thyroid disease
Drug therapy (e.g. warfarin)
Intrauterine contraceptive devices (IUCDs)
Endometrial/cervical carcinoma.
Despite appropriate investigations, often no pathology can be identified. Bleeding of
endometrial origin (BEO) is the diagnosis of exclusion. This replaces the older dysfunctional
uterine bleeding (DUB). Disordered endometrial prostaglandin production has been
implicated in the aetiology of BEO, as have abnormalities of endometrial vascular
development.
4. Relevant menstrual history and what are the abnormal findings
5. Significance of other Hx

6. Relate abnormal findings with sign and symptoms

(gyaneo by ten teachers)

7. Relevant lab investigation

8. Interpret the lab findings
Full blood count
A full blood count (FBC) should be carried out in all women with HMB to ascertain the need
for iron therapy (and in certain cases, blood transfusion).
Coagulation screen
Referral for a haematological opinion should be considered in women with a history
consistent with a coagulation disorder (see Table 5.1).
Pelvic ultrasound scan
A pelvic ultrasound scan (USS) should be performed:
when a pelvic mass is palpated on examination (suggestive of fibroids);
when symptoms suggest an endometrial polyp, e.g. irregular or intermenstrual bleeding;
when drug therapy for HMB is unsuccessful.
High vaginal and endocervical swabs
High vaginal and endocervical swabs should be taken:
when unusual vaginal discharge is reported or observed on examination;
where there are risk factors for PID.
Endometrial biopsy Biopsy should be performed:
in those aged >45 years;
if irregular or intermenstrual bleeding;
drug therapy has failed.
A Pipelle endometrial biopsy can be performed in the outpatient setting. It is performed as
follows:
a speculum examination is carried out and the cervix is completely visualized;
a vulsellum instrument may be required to grasp the cervix and provide gentle traction,
thereby straightening the endocervical canal;
the Pipelle sampler (Figure 5.3) is carefully inserted through the cervical os until it
reaches the fundus of the uterus. The length of the uterus is noted;
the inner part of the Pipelle is withdrawn to create a vacuum and the device is gently
moved in and out to obtain a sample of endometrial tissue;
the Pipelle is removed and the tissue is expelled into a histopathology container of
formalin.
An outpatient hysteroscopy (Figure 5.4) with endometrial biopsy may be indicated if:
Pipelle biopsy attempt fails;
Pipelle biopsy sample is insufficient for histopathology assessment;
there is an abnormality on USS, e.g. suggested endometrial polyp or submucosal fibroid;
patient is known to poorly tolerate speculum examinations (more comfortable
vaginoscopic approach can be used).
If the patient fails to tolerate an outpatient procedure or the cervix needs to be dilated to
enter the cavity, then a hysteroscopy and endometrial biopsy under general anaesthetic may
be required.
Thyroid function tests.
This should only be carried out when the history is suggestive of a thyroid disorder.

9. Normal histology of endometrium

10. Normal structure of uterus and ovary
11. What is pap smear
A Pap test is a test of a sample of cells taken from a woman's cervix or vagina. The test is
used to look for changes in the cells of the cervix and vagina that show cancer or conditions
that may develop into cancer.
It is the best tool to detect precancerous conditions and hidden, small tumors that may lead
to cervical cancer. If detected early, cervical cancer can be cured.
The Pap test is done during a pelvic exam. A doctor uses a device called a speculum to widen
the opening of the vagina so that the cervix and vagina can be examined. A plastic spatula
and small brush are used to collect cells from the cervix. After the cells are taken, they are
placed into a solution. The solution is sent to a lab for testing.
12. Complication of menorrhagia
Excessive or prolonged menstrual bleeding can lead to other medical conditions, including:

Iron deficiency anemia. In this common type of anemia, your blood is low in
hemoglobin, a substance that enables red blood cells to carry oxygen to tissues. Low
hemoglobin may be the result of insufficient iron.
Menorrhagia may decrease iron levels enough to increase the risk of iron deficiency
anemia. Signs and symptoms include pale skin, weakness and fatigue. Although diet
plays a role in iron deficiency anemia, the problem is complicated by heavy menstrual
periods.
Most cases of anemia are mild, but even mild anemia can cause weakness and fatigue.
Moderate to severe anemia can also cause shortness of breath, rapid heart rate,
lightheadedness and headaches.

Severe pain. Along with heavy menstrual bleeding, you might have painful menstrual
cramps (dysmenorrhea). Sometimes the cramps associated with menorrhagia are severe
enough to require prescription medication or a surgical procedure.

13. What is DUB

Dysfunctional uterine bleeding (DUB) is irregular uterine bleeding that occurs in the absence
of recognizable pelvic pathology, general medical disease, or pregnancy. It reflects a
disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial
lining. The bleeding is unpredictable in many ways. It may be excessively heavy or light and
may be prolonged, frequent, or random.

14. Pathophysiology of DUB

Patients with dysfunctional uterine bleeding (DUB) have lost cyclic endometrial stimulation
that arises from the ovulatory cycle. As a result, these patients have constant, noncycling
estrogen levels that stimulate endometrial growth. Proliferation without periodic shedding
causes the endometrium to outgrow its blood supply. The tissue breaks down and sloughs
from the uterus. Subsequent healing of the endometrium is irregular and dyssynchronous.
Chronic stimulation by low levels of estrogen will result in infrequent, light DUB. Chronic
stimulation from higher levels of estrogen will lead to episodes of frequent, heavy bleeding.

15. Management of DUB

MANAGEMENT
Medical Treatment
Non Steroidal Anti-Inflammatory Drugs
Endometrial prostaglandins are elevated with excessive menstruation, and he non- steroidal
anti-inflammatory drugs (NSAIDs) reduce prostaglandin levels through the inhibition of the
cyclo-oxygenase enzyme with reductions in menstrual blood loss of 25-35% (Irvine &,
Cameron, 1999; level 9). NSAIDs are found to be less effective than tranexamic acid or
danazol, but as effective as other medical treatments (Lethaby, Irvine & Cameron, 2003;
level 1), with the added advantage of relieving dysmenorrhoea (Fraser et al,1981; level 3)
Progestogens
Progestogens administered from the fifteen th day or from 19th - 26th day of the menstrual
cycle were significantly less effective in reducing menstrual blood loss when compared to
other medical therapies (Lethaby, Irvine & Cameron, 2003; level 1), and found to be one of
the least effective agents (Roy & Bhattacharya, 2004; level 5). However, progestogen
therapy administered for 21 days of the menstrual cycle results in a significant reduction in
menstrual blood loss, (Lethaby, 2003b; level 1), although they have been found to be
ineffective unless taken at high doses (Irvine & Cameron, 1999; level 9).
Combined oral contraceptive pills
The combined oral contraceptive pill (OCP) in addition to providing contraception causes a
50% reduction in menstrual blood loss by regular shedding of a thinner endometrium and by
inhibiting ovulation (Irvine & Cameron, 1999, level 9).
Danazol
Danazol is a synthetic steroid that suppresses oestrogen and progesterone receptors in the
endometrium, leading to endometrial atrophy (thinning of the lining of the uterus) and
reduced menstrual loss. It is an effective treatment for heavy menstrual bleeding. However,
its side-effect profile, its lack of acceptability to women and the need for continuing
treatment limits its use (Roy & Bhattacharya, 2004; level 5; Beaumont et al, 2003; level 1).

Anti-fibrinolytic agents
Tranexamic acid, a synthetic derivative of the amino acid lysine, exerts an antifibrinolytic effect through reversibleblockade on plasminogen, producing a 50% reduction in
menstrual loss (Irvine & Cameron, 1999; level 9). Anti-fibrinolytic therapy causes a greater
reduction in objective measurements of heavy menstrual bleeding compared to placebo or
other medical therapies (Lethaby, Farquhar & Cooke 2003; level 1Bonnar & Sheppard, 1996,
level 1),and is not associated with an increase in side effects (Lethaby, Farquhar & Cooke,
2003; level 1, Lindoff, Rybo & Astedt, 1997; level 5).
Levonorgestrel intrauterine system
The levonorgestrel intrauterine system (LNG IUS) is a T shaped intrauterine device releasing
a steady amount of levonorgestrel (20 g /24 hours) from a steroid reservoir around the
vertical stem of the device. It reduces menstrual blood loss by 80% (Irvine & Cameron, 1999;
Level 9), and is found to be more effective than cyclical norethisterone, with patients being
more satisfied and willing to continue with treatment. However, these patients experience
more side effects such as inter-menstrual bleeding and breast tenderness (Lethaby, 2003;
level 1). Compared to transcervical resection of the endometrium (TCRE), the LNG IUS
produces smaller mean reduction in menstrual blood loss, but there is no difference in the
rate of satisfaction with treatment. LNG-IUS appears equally beneficial in improving quality
of life and may control bleeding as effectively as conservative surgery over the long term
(Marjori banks, Lethaby, & Farquhar, 2003; level 1).
GnRH agonists
Gonadatrophin-releasing hormone (GnRH) agonists induce a reversible
hypoestrogenic state, reducing total uterine volume. They are highly effective, but their sideeffects make them suitable only for short-term use (Irvine & Cameron, 1999, level 9).GnRH
agonists may obviate emergency surgery in patients with high surgical risk (Vercellini, 1992;
level 3).

Surgical Management
Medical versus surgical treatment
Medical treatment for menorrhagia is not as effective as surgery despite improvement in
control of bleeding. Oral medical therapy is associated with higher incidence of side effects,
and approximately 60% of women who had medical treatment would require surgery by 2
years. Surgery has been found to reduce menstrual bleeding more than medical treatment
at one year, although the majority of women prefer medical treatment (Marjoribanks,
Lethaby & Farquhar, 2003; level 1).
Dilatation and curettage
There is little evidence on the effectiveness of dilatation and curettage (D&C) for the relief of
menorrhagia.It is not cost effective for the diagnosis of endometrial malignancy in women
under 40 years since the prevalence of serious uterine conditions and endometrial cancer is
low (Coulter et al,1993; level 9). The potential benefits need to be weighed against the risks
of anaesthesia and possible complications like uterine perforation and laceration of the
cervix (MacKenzie & Bibby,1978; level 9).Moreover, a significant proportion of endometrial
lesions are not detected by D&C, (Vessey, Clarke, & MacKenzie, 1979) and its usefulness as a
diagnostic tool has been repeatedly questioned. D&C may have a diagnostic role when
endometrial biopsy is inconclusive and the symptoms persist or when the underlying
pathology is suspect.
Endometrial destruction
Endometrial destruction procedures are less invasive, more convenient and less expensive
when no other gynecological condition is involved. It enables women to avoid major surgery
and results in shorter hospital stay and convalescence. The various energy sources used to
destroy the endometrium, are all comparable in terms of efficacy, and the re-operation rate
ranges from 0 to 38.2%. The rate is higher in women under the age 35 years in studies where
they have been observed for longer duration. The first-generation techniques involve lower
costs than a hysterectomy, but the second-generation endometrial destruction techniques
involve relatively high purchase and disposable supplies costs. However, these new
techniques take less time to perform and have a lower incidence of intra-operative
complications. The clinical impact of these two benefits has yet to be demonstrated
(AETMIS, 2002; level 1).
Hysterectomy
Hysterectomy is the most widely used treatment, and can be performed abdominally,
vaginally or laparoscopically. The vaginal and laparoscopic approaches cause fewer
complications and provide a shorter hospital stay and convalescence than abdominal
hysterectomy. Although with hysterectomy there is a permanent cessation of menstrual
flow resulting in a high level of satisfaction, it is a major invasive procedure incurring
morbidity, mortality and costs with a risk oflate complications as well. (AETMIS, 2002; level
1). Laparoscopic assisted vaginal hysterectomy is associated with longer operating times,
and higher operating costs, but total costs are lower than abdominal hysterectomy.