Heavy Mens. Bleeding Flashcards
Average blood loss during menses
30-40 ml
Blood loss in HMB
> 80 ml
How many women describes her menses as heavy
One Third of women
first thing to investigate in abnormal uterine bleeding in childbearing women
Exlude pregnancy (bhcg test)
AUB before puberty may be?
- foreign body
- precocious puberty
AUB in post menopausal women
- atrophic vaginitis/endometritis (common)
- endometrial hyperplasia/ cancer (serious)
Causes of AUB
FIGO classification
DUB IDIOPATHIC: 40-60%
Non structural (COEIN)
1. Coagulation disorders (vonWillberand dis)
2. Ovulation disorders (PCOs)
3. Endometrial disorders
4. Iatrogenic (anticoagulants-chemotherapy- IUCD)
5. Non specific (HTN-Liver troubles- hypothyroidism)
Structural: PALM
1. Polyps
2. Adenomyosis
3. Leiomyomas
4. Malignancy (end. Cx. Ovarian)
HOW IUCD cause AUB
Blood loss may increase 40-60% over 6-12 months
Risks and complications of HMB
• Affects QOL by limiting normal activities, social life, and work.
• Woman’s sex life may be negatively affected.
• Mood changes.
• Iron deficiency anaemia in about two thirds of women.
Which history along with HMB suggests the presence of an intrauterine or uterine pathology?
- Intermenstrual bleeding
- Pelvic pain
- pressure symptoms
Which history along with that of HMB suggests the presence of an intrauterine or uterine pathology?
Intermenstrual bleeding
Pelvic pain or pressure symptoms
Is physical examination mandatory for all HMB patients ?
No - not if the only complaint is HMB
To be done - only if intermensterual bleeding,pelvic pain or pressure symptoms present & before fitting LNG IUS
Which lab investigations are done in cases of HMB
CBC - for all HMB
Coagulation tests - if HMB since menarche and positive personal or family history for coagulation disorders
Thyroid - only if signs and symptoms present
Which is the 1st line investigation if you suspect an intrauterine pathology - like endometrial pathology, polyp, submucosal fibroid ?
Outpatient hysteroscopy
If shed declines Offer under SA or GA
If declines that also, TVS. But explain the limitations
Should blind endometrial sampling be taken investigating HMB
No
When is TVS the 1st line investigation for HMB
Palpable uterus
Pelvic mass suspected on history or examination
Obese patient
If she declines:
TAS or MRI
Explain the limitations
1st line management for females with only HMB. No pathology?
LNG IUS
Also for adenomyosis and fibroids < 3 cm
What if women with no pthological HMB DECLINDES LNG-IUS
-Non hormonal
-Hormonal
What if women with no pathological HMB refused pharmaceutical options
Surgical - 2nd line endometrial ablation
Hysterectomy
Management of large fibroids
Non hormonal
Hormonal
UAE
Surgical - Myomectomy, Hysterectomy
2nd line medical treatment in HMB
Trenaxemic acid + NSAIDS
When NSAIDS AND TRENEXAMIC ACID indicated in treating HMB
- If hormonal treatments are not acceptable to the woman.
- If contraception is not desired.
- Can be commenced as first-line drugs while investigations or definitive treatment is being organized.
How long she could take trenaxemic acid in ttt of HMB
Ongoing use is recommended for as long as they are found to be beneficial.
When use of trenaxemic acid should be stoped when ttt HMB
Use should be stopped if it does not improve symptoms within three menstrual cycles.
Third line medical management of HMB
- Oral norethisterone (NET, 15 mg) daily from D5–26: not used if pregnancy desired (steronate)
- Depot medroxyprogesterone acetate (DMPA): bleeding stops completely
- don’t use oral progestogens used in luteal support in ttt of HMB
What is TXA (trenaxemic acid)
Anti fibrinolytic = kapron
Typical dose of TXA
500 mg Tds on bleeding days
SE of TXA
indigestion, diarrhoea, headaches.
How do COCs ttt HMB
suppresses ovulation and endometrial proliferation, thereby decreasing menstrual fluid volume and prostaglandin secretion; regulates cycles.
Indications of COCs use
- HMB.
- Dysmenorrhoea.
- Contraceptive.
Indications of COCs use
- HMB.
- Dysmenorrhoea.
- Contraceptive.
SE of COCs
mood changes, headaches, nausea, fluid retention, breast tenderness, DVT, stroke, heart attacks.
Mechanism of action of GNRHa
stops ovarian production of oestrogen and progesterone. In 89% of women, bleeding stops completely.
GNRH-a indications in case of HMB
could be considered prior to surgery or when all other treatment options for uterine fibroids, including surgery or UAE, are contraindicated.
Typical dose of GNRH-a in treating of HMB
3.6 mg implant every 4 weeks.
Gnrh-a SE
- menopausal symptoms
- vaginal dryness
- osteoporosis, particularly trabecular bone
with longer than 6 months use.
Do we need giving ERT after GNRHa
If this treatment is to be used for > 6 months or if adverse effects are experienced, then HRT ‘add-back’ therapy is recommended.
Oral norethisterone mechanism of action in ttt of HMB
(Progestogens) prevents proliferation of the endometrium.
Oral norethisterone typical dose
15 mg daily from D5 to D26.
Oral norethisterone SE
weight gain, bloating, breast tenderness, headaches, acne, depression.
Mode of action of LNG-IUD
slowly releases progestogen locally and prevents proliferation of the endometrium.
Duration of effect of LNG-IUD
5 years
LNG-IUD INDICATIONS
- HMB.
- Contraceptive.
- Endometriosis.
LMG-IUD side effects
irregular bleeding that may last for over 6 months
hormone-related problems such as breast tenderness, acne, or headaches (minor and transient)
amenorrhoea
uterine perforation at the time of IUD insertion.
Mechanism of action of DMPA
it is a long-acting progestogen. Works primarily by suppressing ovulation; prevents proliferation of the endometrium.
Mechanism of action of DMPA
it is a long-acting progestogen. Works primarily by suppressing ovulation; prevents proliferation of the endometrium.
DMPA typical dose in ttt HMB
IM injection every 12 weeks
DMPA side effects
weight gain
irregular bleeding
amenorrhoea
premenstrual-like syndrome
small loss of bone mineral density
largely recovered when treatment is discontinued.
Surgical options in treating HMB, normal uterus with or without fibroid <3 cm
Endometrial ablation
Surgical options in treating HMB, uterus with fibroid >3cm
Uterine artery Embolization
Myomectomy
How does endometrial ablation works
Removes or destroys the womb lining and stops heavy bleeding. Results in clinically relevant reduction in bleeding and improvement in QOL.
HMB accounts for how many outpatient referrals to gynaecology?
20%
SBA
What is the 1ry aim of medical intervention in management of HMB
Improving women’s QOL
