[33] Menorrhagia Flashcards by Elliot Jones

What is the techinical definition of menorrhagia?

> 80ml/month of loss

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What % of women are affected by menorrhagia?

10%

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What is the clinical definition of menorrhagia?

Excessive menstrual loss leading to interference with physical, emotional, social or material quality of a woman’s life

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What type of conditions are most commonly causing menorrhagia?

Benign ones

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What can menorrhagia often lead to?

Iron deficiency anaemia

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What can iron-deficiency have an impact on?

Woman’s work, family and social life

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What are the groups of causes of menorrhagia?

Structural
Non-structural
Iatrogenic

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What are the possible structural causes of menorrhagia?

Leiomyomata
Endometrial carcinoma
Adenomyosis
Polyps
Endometrial hyperplasia

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What is the more common term for leiomyomata?

Fibroids

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What is the most common structural cause of menorrhagia?

Fibroids

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When is endometrial cancer more rare?

Under 40 years

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What is endometrial cancer more likely to cause before menorrhagia?

Irregular bleeding

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What is adenomyosis usually associated with?

Uniformly enlarged, tender uterus, menorrhagia and dysmenorrhoea

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What do polyps usually cause as well as menorrhagia?

IMB

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What can endometrial hyperplasia be associated with?

Irregular anovulatory cycles and overlap with disturbed ovulation

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What can endometrial hyperplasia be a precursor of?

Endometrial cancer

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What are the non-structural causes of menorrhagia?

Disturbed ovulation or anovulation

- Disturbed mechanisms of endometrial haemostasis

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How else can disturbed ovulation or anovulation affect the menstrual cycle?

Irregular
Infrequent
Prolonged
Potentially life-threatening bleeding

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How does disturbed ovulation causing menorrhagia?

Unopposed oestrogen leading to thickening and hyperplasia of the endometrium which then breaks down in a patchy and erratic fashion

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When do most cases of ovulatory disorders occur?

Menopause transition
Adolescence
Due to endocrinopahties

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What endocrinopahties can cause ovulatory disorders?

PCOS

- Hypothyroidism

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What can cause disturbed mechanisms of endometrial haemostasis?

Excessive local production of fibrinolytic factors e.g. TPA
Deficiencies in local vasoconstrictors
Increased local vasodilators

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What is a common iatrogenic cause of menorrhagia?

Copper IUD

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Why should women with menorrhagia have a general examination?

For signs of anaemia or thyroid disease

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What additional examinations may women with menorrhagia require?

- Pelvic - Speculum - Smear

What is the first line test for menorrhagia?

Bloods

What bloods are useful when assessing menorrhagia?

- FBC - Serum ferretin - Serum transferrin receptor

When can treatment be started after blood tests alone for menorrhagia?

If examination and history were not of a sinister nature

When should patients with menorrhagia be referred for further investigation?

- Risk factors for endometrial cancer - Persistent IMB - Abnormal cervical smear - Significant pelvic pain - Not responding to first-line treatment after 6 months

What is the purpose of further investigations for menorrhagia?

To exclude pelvic pathology, particularly malignancy

What are the main forms of additional investigation for menorrhagia?

- Transvaginal USS - Endometrial biopsy - Hysteroscopy - Investigations for systemic causes - Thyroid screening

What can transvaginal USS identify in menorrhagia?

Presence of structural lesions e.g. polyps

What does hysteroscopy provide in menorrhagia?

View of uterine cavity

How can hysteroscopy be performed?

Under local or general anaesthetic

What is an important investigation for systemic causes of menorrhagia?

Coagulation screen for disorders of haemostasis

Give an example of a clotting disorder that can cause menorrhagia?

Von Willebrand's disease

When is coagulation screening indicated in menorrhagia?

- Young women | - History/family history of coagulopathies

When is a thyroid screening indicted in menorrhagia?

Suggestive features in history or on examination

What are the main types of treatment for menorrhagia?

- Medical | - Surgical

What does the medical management of menorrhagia in the absence of malignancy depend on?

- If contraception is required - If irregularity is an issue - Presence of any contraindications

How can the medical treatments of menorrhagia be divided?

- Hormonal | - Non-horomonal

What is the advantage of non-hormonal treatments for menorrhagia?

Only need to be taken when menstruating

What are some non-hormonal medications used in menorrhagia?

- NSAIDs | - Tranexamic acid

What are some examples of NSAIDs used in menorrhagia?

- Megenamic acid | - Ibuprofen

What is the mechanism of action of NSAIDs?

Reduce prostaglandin synthesis

By how much can NSAIDs reduce blood loss in menorrhagia?

30%

What is a secondary advantage of NSAIDs for menorrhagia?

Analgesic properties

What is the main side effect of NSAIDs?

Gastric irritation

What sort of drug is tranexamic acid?

Antifibrinolytic

By how much does tranexamic acid reduce blood loss in menorrhagia?

50%

Who should tranexamic acid be avoided?

People with a history of thromboembolic disease

What are the options for the hormonal management of menorrhagia?

- COCP - Levonorgestrel IUS - Synthetic oral progesterones

What % of monthly blood loss reduction can COCP give?

~30%

What % of monthly blood loss reduction can levonorgestrel IUS give?

~90%

In what regime are oral progesterones given to treat menorrhagia?

21/28 days

When can oral progesterones be given in higher doses for menorrhagia?

In an acute situation to control excessive bleeding

What is the problem with oral progesterones for menorrhagia?

Associated with more side-effects

What is the recommended first line treatment for menorrhagia?

IUS

What are the main surgical treatments for menorrhagia?

- Endometrial resection - Endometrial ablation - Hysterectomy

What is endometrial resection?

Removal of the endometrium with hysteroscope

What is endometrial ablation?

Destruction of the endometrium using intrauterine heating/cooling devices

What treatment can be given prior to endometrial ablation?

GnRH analogues to thin the endometrium

What are the potential complications of endometrial ablation?

- Intraoperative uterine perforation - Damage to other organs - Fluid overload - Need for further surgery

What new techniques for endometrial ablation are emerging?

Balloon ablation

What is the advantage of balloon ablation?

Allow for precise destruction of the endometrium reducing side effects

What % of patients who have ablation will be amenorrhoeic post-op?

30-70%

What % of patients will have significant reduction in menstrual bleeding after ablation?

20-30%

What is the definitive surgical treatment for menorrhagia?

Hysterectomy

Who is hysterectomy most appropriate for in menorrhagia?

Those with pelvic pathology e.g. fibroids