Heavy Menstrual Bleeding

Question 1

Menorrhagia is defined as excessive menstrual blood loss of ____ mL or more, and/or for a duration of more than ____ days, which results in the ended to change menstrual products every ______ hours.

Answer 1

80 mL or more

7 days

1-2 hours

(Occurs regularly every 24-35 days)

Question 2

What 4 factors guide the treatment of menorrhagia?

Answer 2

1. Presence or absence of fibroids (including size, number, and location), polyps, endometrial pathology, or adenomyosis
2. Other symptoms (such as pressure or pain)
3. Co-morbidities
4. Patient preference

Question 3

Levonorgestrel IUS is first line in which 3 cases of heavy menstrual bleeding?

Answer 3

1. Unidentified pathology
2. Fibroids less than 3 cm in diameter causing no distortion of the uterine cavity
3. Suspected or diagnosed adenomyosis

Question 4

When patients are commenced on treatment with a levonorgestrel IUS, they should be advised that irregular menstrual bleeding can occur particularly during the first ________ of use and that the full benefit of treatment may take at least _____ months.

Answer 4

Month

6

Question 5

If a levonorgestrel-releasing intrauterine system is unsuitable, either_______________, an _________, a________________, or a ______________ should be considered

Answer 5

tranexamic acid (antifibrinolytic)

NSAID (eg mefanamic acid)

combined hormonal contraceptive

cyclical oral progestogen

*a non-hormonal contraceptive is preferred in patients actively trying to conceive

Question 6

What are the main options for patients in whom drug treatment for menorrhagia is unsuccessful or declined, or if symptoms are severe?

Answer 6

Referral to a specialist for alternative drug treatment

OR

Surgery

Question 7

In females with menorrhagia and fibroids of _____ cm or more in diameter, referral to a specialist should be considered.

Answer 7

3

Treatment options include tranexamic acid, an NSAID, a levonorgestrel-releasing intrauterine system, a combined hormonal contraceptive, a cyclical oral progestogen, ulipristal acetate, uterine artery embolisation, or surgery. Treatment choice depends on the size, number and location of the fibroids, and severity of symptoms.

Question 8

Intermittent ______________ can be offered to treat moderate to severe symptoms of uterine fibroids in premenopausal women where surgery and uterine artery embolisation are unsuitable, or have failed

Answer 8

ulipristal acetate

Question 9

If drug treatment is required while investigations and definitive treatment is being organised for menorrhagia, either ____________, or an ________, or both, can be given

Answer 9

tranexamic acid

NSAID

Question 10

The effectiveness of drug treatment for heavy menstrual bleeding may be limited in females with fibroids that are substantially greater than _____ cm in diameter.

Answer 10

3

Treatment with a gonadotrophin-releasing hormone analogue before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus

Question 11

Treatment with a______________ before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus

Answer 11

gonadotrophin-releasing hormone analogue

Question 12

What is the mechanism of action of tranexamic acid?

Answer 12

Anti fibrinolytic

Question 13

What is the mode of administration of tranexamic acid in the treatment of menorrhagia?

Answer 13

PO

1g TDS for up to 4 days, to be initiated when menstruation has started
Max 4 g per day

Question 14

What are the contraindications to the use of tranexamic acid? (3)

Answer 14

1. Fibrinolytic conditions following DIC
2. PMHx of convulsions
3. Thromboembolic disease

Question 15

Should tranexamic acid dose be adjusted in the context of renal impairment?

Answer 15

Yes, reduce dose