Professional Documents
Culture Documents
Menorrhagia
(Heavy Menstrual
Bleeding)
1
Definition
In
research studies-between 60ml and 80ml per
menstruation–not practical in the clinical setting
may be accompanied by other symptoms , such as
menstrual pain ( dysmenorrhoea )
2
Normal Menstrual Cycle
•Cycle length
–average 29 days
–Range 21 - 35 days
•Duration of flow
–Average 4 days
–3 to 7 days
•Amount
–Average 35 mls
•Quality– Non-clotting blood , endometrial debris
3
Previously………….
•In the early 1990s it was estimated that at
a woman’s identity
undesirable for some people
4
Now………….
health care
•Never the less , clinically , hysterectomy Is
5
Risk Factors
6
2•Polyps
3•Blood disorders
von Willebrand disease (vWD)
•13.0-15.4 % in women with menorrhagia
compared with the general population
7
4•Thyroid disorders
5 •Endometriosis / Adenomyosis
-usually dysmenorrhoea but two studies have
found that HMB may be a significant
secondary symptom
6•Racial groups
8
7•Uterine Pathology?
– Results of 20 observational and diagnostic
studies show that the majority of women with
HMB have no histological abnormality that can
be implicated in causing HMB
–Rare for a woman who has presented with HMB
and has undergone investigations to have an
underlying pre-malignant or malignant condition
-RCOG (Royal College of Obstetricians and Gynaecologists)
•women aged between 35 and 54 years , eight of
every 10,000 women who presented with HMB in
primary care would have endometrial carcinoma.
9
8•Dysfunctional uterine bleeding ( bleeding of
endometrial origin )
–No organic cause
–Frequently due to an ovulation
9•Others
–PID
–Malignancy
–IUCD
–Medications ( Tamoxifen , Un apposed
oestrogen treatment )
10
What is our goal ?
11
How should assess a woman with menorrhagia?
concerns
.Previous treatments
12
Physical examination if an abnormality is
suspected (e.g. if there is intermenstrual or
postcoital bleeding, or pelvic pain or
pressure) -Recommended before all ;
- LNG-IUS fittings (levonorgestrel intrauterine system)
-investigations for structural abnormalities
-investigations for histological abnormalities
13
Measurement of MBL
Direct- alkaline haematin
Accurate and precise
Impractical
Little impact on management
Indirect- Pictorial Blood Loss Assessment
Chart (PBAC)
Highly variable
NOT RECOMMENDED ROUTINELY
SHOULD BE DETERMINED BY PATIENT HERSELF
14
Investigations (Laboratory)
family history
Serum Ferritin - not routinely
Hormone testing - not recommended
Thyroid function test - when signs and
symptoms present
15
Investigations (Structural and Histological)
Ultrasound
sensitivity 48 - 100%
specificity 12 - 100%
better at identifying fibroids than hysteroscopy
less accurate for identifying polyps or endometrial disease
should be undertaken in the following circumstances:
uncertain origin
pharmaceutical treatment fails
Hysteroscopy
when ultrasound results are inconclusive
to determine the exact location of a fibroid or the exact
17
What advice and counselling should I
give to a woman with menorrhagia?
Discuss…….
Natural variability and range of menstrual blood
loss and reassure the woman (if appropriate)
Different treatment options :
acceptability
effectiveness of treatments
adverse effects
contraception
implications of treatment on fertility
18
When should I prescribe
pharmaceutical treatment in
women presenting with
menorrhagia?
19
Drug treatment
20
Drug Treatment
If either hormonal or non-hormonal treatments
are acceptable (descending order) :
levonorgestrel-releasing intrauterine system
21
Drug Treatment
•Levonorgestrel-releasing
intrauterine system (Mirena®)
22
Drug Treatment
Tranexamic acid
o 1 g (2 X 500 mg tablets) three to
23
Drug Treatment
COCs
reduction of MBL of 43%
Oral progestogen
No evidence
Amenorrhea is a side effect (NICE)
24
Drug Treatment
If
hormonal treatments are not
acceptable to the woman, then either
tranexamic acid or NSAIDs can be used
GnRH analogue
o prior to surgery
o other treatment options for uterine fibroids,
25
What should I do if initial drug
treatment is ineffective in a
woman with menorrhagia?
A second pharmaceutical treatment
Add on another drug rather than immediate
referral to surgery.
Use of NSAIDs and/or tranexamic acid
26
How can I rapidly stop heavy
bleeding, if necessary?
Oralnorethisterone, 5 mg three
times daily (licensed use) or, in
very severe cases, 10 mg three
times daily (unlicensed use), then
tapering down to 5 mg three
times daily for a further week
27
Not Recommended
Oral progestogens in the luteal phase only
Danazol (side effects)
Etamsylate
28
When should I refer?
Malignancy is suspected
refer urgently (within 2 weeks)
Significant negative impact on her quality of
29
Surgical Treatment
Used as the initial treatment for HMB?
o Unclear
o Endometrial ablation may be offered
o Hysterectomy should not be used as a first
30
Non-hysterectomy or
interventional radiology
Endometrial ablation
o 1st generation (TCRE, Rollerball)
o 2nd generation (MEA, Inpedence-controlled
bipolar radiofrequency, balloon thermal)
o Affects fertility
o Use of effective contraception following
procedure
o 50% amenorrhoea, 95% satisfaction rate
31
Non-hysterectomy or interventional
radiology
32
Non-hysterectomy or interventional
radiology
Hysteroscopic myomectomy
33
Hysterectomy
Fibroids >3cm + severe impact on QoL
Desire for amenorrhoea
Other treatments failed, contraindicated,
declined
No desire to retain uterus or fertility
Fully informed women request it
34
Hysterectomy
Route
o First line : Vaginal
o Second line : Abdominal
Ovaries may also be removed
100% amenorrhoea
95% satisfaction rate
35
Thank you
36