Heavy Mens. Bleeding Flashcards by Easy MRCOG

Average blood loss during menses

30-40 ml

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Blood loss in HMB

> 80 ml

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How many women describes her menses as heavy

One Third of women

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first thing to investigate in abnormal uterine bleeding in childbearing women

Exlude pregnancy (bhcg test)

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AUB before puberty may be?

foreign body
precocious puberty

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AUB in post menopausal women

atrophic vaginitis/endometritis (common)
endometrial hyperplasia/ cancer (serious)

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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)

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HOW IUCD cause AUB

Blood loss may increase 40-60% over 6-12 months

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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.

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Which history along with HMB suggests the presence of an intrauterine or uterine pathology?

Intermenstrual bleeding
Pelvic pain
pressure symptoms

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Which history along with that of HMB suggests the presence of an intrauterine or uterine pathology?

Intermenstrual bleeding
Pelvic pain or pressure symptoms

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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

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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

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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

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Should blind endometrial sampling be taken investigating HMB

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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

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1st line management for females with only HMB. No pathology?

LNG IUS

Also for adenomyosis and fibroids < 3 cm

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What if women with no pthological HMB DECLINDES LNG-IUS

-Non hormonal
-Hormonal

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What if women with no pathological HMB refused pharmaceutical options

Surgical - 2nd line endometrial ablation
Hysterectomy

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Management of large fibroids

Non hormonal
Hormonal
UAE
Surgical - Myomectomy, Hysterectomy

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2nd line medical treatment in HMB

Trenaxemic acid + NSAIDS

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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