Heavy menstrual bleeding Flashcards
Describe heavy menstrual bleeding?
Excessive (definition set by woman) menstrual loss which interferes with a woman’s quality of life - either on its own or in combination with other symptoms
What percentage of heavy menstrual bleeding cases are found to have no pathology after investigation?
40-60%
Dysfunctional/abnormal uterine bleeding?
Diagnosis of exclusion
Describe heavy menstrual bleeding for which no cause can be found
What is the mnemonic used to classify the causes of heavy menstrual bleeding
PALM-COEIN
What does the PALM-COEIN system divide the causes of heavy menstrual bleeding into?
Structural (PALM) or non structural (COEIN)
List the structural causes of heavy menstrual bleeding
Polyp
Adenomyosis
Leiomyoma (fibroid)
Malignancy and hyperplasia
List the non-structural causes of heavy menstrual bleeding
Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
What are the two main risk factors for heavy menstrual bleeding?
Age
Obesity
At what ages is heavy menstrual bleeding more likely?
Menopause
Menarche
What are the main clinical features of heavy menstrual bleeding?
Bleeding during mensturation deemed excessive for the individual woman
Fatigue
Shortness of breath (anaemia)
What should be asked about in the menstrual history?
Frequency Duration Volume Date of LMP Smear history Contraception Medical history Drug history
What should be looked for on examination of a woman with heavy menstrual bleeding?
General observation - pallor (anaemia)
Abdominal palpation - palpable uterus or pelvic mass, ascertain if the uterus is smooth or irregular (fibroids), tender uterus or cervical excitation point toward adenomyosis/endometriosis
Inflamed cervix/cervical polyp/cervical tumour
Vaginal tumour
What is deemed a frequent period?
<24 days
What is deemed infrequent periods?
> 38days
What is the average duration of bleeding?
5 days
What is prolonged menstruation?
> 8 days
What is shortened menstruation?
<4.5 days
What is the average volume of menstrual blood lost over course of menses?
40ml
What is deemed heavy menstrual blood loss
> 80ml - hb and ferritin affected, women may describe flooding and clots passable
Which coagulopathy is the most common to cause heavy menstrual bleeding?
Von Willebrand’s disease
What investigations would you do for a patient with heavy menstrual bleeding
Urine pregnancy test
Bloods - FBC, TFTs, Hormone testing (eg. for PCOS), Coagulation screen and test for von willebrand’s
Ultrasound pelvis - Transvaginal US is most clinically useful for assessing the endometrium and ovaries
Cervical smear if not up to date
High vaginal and endocervical swabs
Pipelle endometrial biopsy
Hysteroscopy and endometrial biopsy
What are the indications for a pipelle endometrial biopsy?
Persistent intermenstrual bleeding
>45years old
Failure of pharmacological treatment
What is the aim of managing heavy menstrual bleeding?
Improve the woman’s quality of life rather than specific reduction in the volume of blood lost
Describe the 3 tiered approach to treating heavy menstrual bleeding with pharmacological management
Levonorgestrel releasing intrauterine system (LNG-IUS)
Tranexamic acid, mefenamic acid or combined oral contraceptive pill
Progesterone only: oral norethisterone (taken day 5-26) of cycle, depo or implant
What are the two main treatment options for heavy menstrual bleeding?
Endometrial ablation
Hysterectomy
Describe endometrial ablation
Where the endometrial lining of the uterus is obliterated
Who is endometrial ablation suitable for?
Women who no longer wish to conceive - although they will still need to use contraception
How much can heavy menstural bleeding be reduced by when using ablation?
80%
What is the definitive treatment for heavy menstural bleeding?
Hysterectomy
What does hysterectomy offer?
Amenorrhoea
End to fertility
What are the two types of hysterectomy?
Subtotal (partial)
Total
What is a subtotal hysterectomy?
Removal of the uterus but not cervix
What is a total hysterectomy?
Removal of cervix with uterus
Are the ovaries removed in subtotal or total hysterectomy?
No - unless abnormal
How is hysterectomy performed?
Abdominal incision
Via vagina
