Differentials of menorrhagia (AUB)

 Gynae vs non gynae

 Gynae
o Fibroids
o Adenomyosis
o Endometrial polyps
Fibroids History Template o PID
 Demographics o Cancer (esp >40yo)
o IUD
o Must include marital status and sexual activity
o DUB
 Gravidity and parity  Non gynae
 LMP (description) o Antocoagulaton therapy
o Bleeding diathesis
 cycle
o Chronic liver/renal failure
 length and frequency of o Hypothyroidism/hyperthyroidism
menstrual cycle
 amount of menstrual flow
o Number of pads/d
o Flooding
o Clots
 Associated dysmenorrhea if there is when is it in association with
period
 Menarche
 PC & HPC
o Comorbities an/or current medication:
 Comorbidity: bleeding diathesis, chronic liver/renal
failure/hyper/hypothryroidism, (any other that may or may not be related)
duration, complications and current treatment
 Medication: anticoagulation drugs: aspirin, clopidogrel, warfarin, etc, OCPs,
HRT, IUD (copper)
o History of STIs/abnormal discharge PID
o Family history of gynae pathology (fibroids, endometriosis, Cancer)
o Abnormal uterine bleeding
 New cycle
 When did this begin?
 Length & frequency
 Amount – menorrhagia?
o Pads and type
o Flooding
o Clots
 Associated pain - dysmenorrhoea
o Site
o Pattern of pain:
o Before onset of menses
o Increasing as periods progress (clot dysmenorrhoea)
o Lasts throughout the period?
o Continues after period? (endometriosis)
o Character
 Cramping?
o Radiation

By: Noo and Chris 2013

  To the back?
 Down the leg?
o Severity
o Aggravating and relieving factors
o Any dyspareunia
 Superficial vs deep
 Helps rule out endometriosis
o Acute pain
 Do we have acute degeneration?

 Associated inter-menstrual or post-coital bleed

 Symptoms of anaemia-pale mucous membranes, fatigue, lethargy,
palpitations, SOB, etc
 Was this treated? If yes give detailed description of intervention.

o Pressure or bulk symptoms

 Pelvic pressure/heaviness/fullness
 Increasing abdominal girth
 Rate of growth
 Increased jeans size
 Urinary urgency or frequency, nocturia
 Rule out UTI by asking about dysuria, pyuria, haematuria, foul
smelling urine
 Constipation, urgency, tenesmus
o Rule out
 Malignancy
 Fever, weight loss, night sweats
 Last pap smear
o Complications:
 Compressive symptoms
o GI- Constipation
o GU
 Freq.
 Retention
o CVS- Leg Swelling
 Infertility
o ? trying to get pregnant,
o ?any difficulty
 Spontaneous abortion

By: Noo and Chris 2013

  PMH
o All chronic illnesses
 PSH
o Prior surgery for fibroids
 POH
o Gravidity and parity
o Pregnancy losses
o Infertility
 Reproductive desire
 Frequency of sexual intercourse
 Contraception
o Each pregnancy looking for complications
 Malpresentation
 Placenta praevia
 Preterm labour
 Obstructed labour
 Difficult C-Section
 PGH
o Menarche
o Coitarche
o Normal menstrual cycle as in HPC
o Contraception
 Barrier: STI risk
 OCP: risk of abnormal bleeding
o STI history
 Inclusive of partner’s STI risk
 DH
o All drugs with focus on
 Anticoagulants
 Haematinics prescribed
o SH
 Smoking, alcohol
 Effect of condition of ADL’s
o FH
 Uterine fibroids
 Malignancy
 Endometrial, cervical, ovarian, breast, colorectal
 Bleeding diathesis
 Chronic illnesses

By: Noo and Chris 2013

TREATMENT
Depends on:
 Symptomatic/Asymptomatic
 Size
 Reproductive desires of patient
 Age of patient

Physical Exam:
- General: Vital Signs – BP, PR to r/o shock; pallor & other signs of anaemia, thyroid

- Bimanual: to assess uterine size, position, contour & adnexal masses eg. ovarian cysts etc.

- Speculum: r/o vaginal d/c, cervicitis & cervical erosion

Investigations:
- CBC (Hb, Plt, PCV, PT/PTT) – assess severity of anaemia/baseline for possible surgery
- ± Serum Fe, Ferritin level (if Hx or PE suggest) – quantifies Fe def. anaemia
- ± TFT (if Hx or PE suggest) – r/o hypothyroidism
- Pelvic U/S: assess fibroids, endometrial thickness (N<5mm; if > 5mm proceed to
endometrial sampling via D&C or Pipell’s
- Pap Smear
- ± Saline Infusion Sonogram

Options:
 No Treatment (eg. in perimenopausal females, as fibroids normally show regression after
menopause)

 Medical

1st Line Treatment

o COCP
 MOA: unclear, probably via induction of endometrial atrophy
 ADV: also provide effective contraception & help in ↓ period pain by
producing anovular cycles
 S/E: Nausea, headaches, migraine, weight gain, HTN, thrombosis, mood
changes
 C/I: pt’s prone to vascular thromboembolic (VTE) disease (eg. SCD),
smoking (as ↑ rate of dvpmt. of VTE disease)
o Depoprovera
 S/E: irregular bleeds w/ depo
o Mefenamic acid
 PG synthetase inh.
 ADV: additional use in pts w/ dysmenorrheal
 Dose: 500mg tid for duration of menses & can be continued over long
periods

2nd Line Treatment

o Danazol

By: Noo and Chris 2013

 
Isoxazol derivative of 17-α-ethinyl testosterone with miold androgenic
properties
 MOA: inh ovulation → low circulating oestrogen levels & endometrial
atrophy
 Dose: 200mg ↓ blood loss by ~60%
 S/E: Headache, Weight gain, acne (oily skin), m. cramps, hirsutism,
voice change, skin rashes; LIMITS ITS USE
o GnRH Analogues x 3-6/12
 MOA: down regulation of GnRH receptors of gonadotrophes in ant. pituitary
→ desensitisation & suppression of LH & FSH release → suppression of
ovarian function & low oestrogen levels (→ shrinkage of fibroids by ~50%)&
amenorrhea
 ADV:
 highly effective in inhibiting menstrual loss therefore correcting Fe-
def anaemia if present
 useful as pre-treatment methods prior to endometrial ablation
techniques (4-8 weeks prior) since endometrium is thinned
effectively with these agents
 perimenopausal women are spared surgery
 DISADV: High recurrence of fibroids once discontinued; EXPENSIVE
 Surgical

o Myomectomy

NB: retains reproductive potential cf. hysterectomy

 Indications: if symptomatic i.e. pain, menorrhagia or mass effect
 Contraindications: During C-section (unless fibroids obstructing delivery of
fetus) b/c of possibility of profuse haemorrhage
 Methods: Laparotomy, Hysteroscopically (ltd. to submucous fibroids),
Laparoscopy (use restricted to solitary & small pedunculated fibroids)
 Complications:
(i) significant blood loss intra-op, therefore pt. should be GXM
≥2U of blood pre-op in prep for blood transfusion
(ii) risk of post-op adhesion on uterus, which can compromise
future fertility
(iii) scar fmtn. → ↑ risk of dehiscence of pregnant uterus
necessitating delivery via C-section in subsequent
pregnancies
(iv) Recurrence of fibroids (42-55%)

o Uterine Artery Embolization

 Less invasive hence suitable for patients wanting to avoid surgery

 Leads to reduction insize of fibroids & symptoms
 Method: canalization of uterine A. w/ a catheter using polyvinyl alcohol to
cause embolization of A. thus occluding blood supply to uterus → ischaemia
results in shrinkage of fibroids
 Disadv: not as efficacious as hysterectomy in elimination of menstrual
symptoms

By: Noo and Chris 2013

 o Hysterectomy

 Definitive treatment of symptomatic uterine fibroids in:

 patients who have completed their families
 females > 40 years
 Asymptomatic large fibroids
 Methods:
 Total Abdominal Hysterectomy ± Bilateral Salpingo-Oophorectomy
NB: conservation of ovaries in young patients as removal of both ovaries =
surgical castration & need for hormone replacement therapy for life

 Subtotal Hysterectomy in young women

o ADV: shorter operation time, fewer intra-op complications
esp injury to bladder & ureters, >er satisfaction w/ sexual
intercourse & absence of vault complication

By: Noo and Chris 2013