Heavy Menstrual Bleeding Flashcards
What is Heavy Menstrual Bleeding?
Excessive menstrual loss which interferes with a woman’s quality of life
What percentage of women experience Heavy Menstrual Bleeding?
3%
What age group of women are most affected by Heavy Menstrual Bleeding?
40-51 years old
What is the mnemonic used to divide the different causes of Heavy Menstrual Bleeding?
Palm-Coein
What does the PALM bit of the Palm-Coein mnemonic mean?
Structural causes of Heavy Menstrual Bleeding:
P – Polyp
A – Adenomyosis
L – Leiomyoma (Fibroid)
M – Malignancy / hyperplasia
What does the COEIN bit of the Palm-Coein mnemonic mean?
Non-structural causes of Heavy Menstrual Bleeding:
C – Coagulopathy
O – Ovulatory dysfunction
E – Endometrial
I – Iatrogenic
N – Not yet classified
What are the main risk factors for Heavy Menstrual Bleeding? (2 things)
- Age
- Obesity
What are the CF of Heavy Menstrual Bleeding? (3 things)
- Bleeding
- Fatigue
- SOB (if associated anaemia)
What are you looking for @ examination of Heavy Menstrual Bleeding patient? (4 things)
- Pallor (anaemia)
- Palpable uterus / pelvic mass
- Inflamed cervix / cervical polyp / tumour
- Vaginal tumour
What are you suspecting if a Heavy Menstrual Bleeding patient has an irregular uterus @ examination?
Fibroids
What are you suspecting if a Heavy Menstrual Bleeding patient has a tender uterus / cervical excitation @ examination? (2 things)
- Adenomyosis
- Endometriosis
What are the differential diagnoses for Heavy Menstrual Bleeding? (9 things)
- Pregnancy
- Endometrial / cervical polyps
- Adenomyosis
- Fibroids
- Malignancy / endometrial hyperplasia
- Coagulopathy
- Ovarian dysfunction
- Iatrogenic causes
- Endometriosis
What are the CF of Endometrial / cervical polyps? (3 things)
- Intermenstrual bleeding
- Post-coital bleeding
- NOT associated w dysmenorrhea (painful periods)
What are the CF of Adenomyosis? (2 things)
- Dysmenorrhea
- Bulky uterus (@ exam)
What are the CF of Fibroids? (2 things)
- Hx of pressure symptoms (e.g urinary frequency)
- Bulky uterus (@ exam)
What is the most common Coagulopathy to cause Heavy Menstrual Bleeding?
Von Willebrand’s disease
What are the CF of Von Willebrand’s disease? (5 things)
- HMB since menarche
- PPH Hx
- Surgical / dental related bleeding (bleeding gums)
- Easy bruising / epistaxis
- Bleeding disorder FHx
What should you consider for pt w Von Willebrand’s disease?
Warfarin (anti-coagulant)
What are the most common causes of Ovarian dysfunction? (2 things)
- PCOS
- Hypothyroidism
What are the iatrogenic causes of HMB? (2 things)
- Contraceptive hormones
- Copper IUD
What percentage of all HMB does Endometriosis represent?
Less than 5%
What investigations should you do for HMB? (5 things)
- Urine pregnancy test
- FBC
- TFT
- Hormone tests (e.g if sus PCOS)
- Coag screen (+ check for Von Willebrand’s) if sus
Why should you do a FBC for HMB?
Anaemia presents after 120ml menstrual blood loss
When should you do a TFT for HMB?
If has other signs of hypothyroidism
What imaging should you do for HMB?
Transvaginal US
What is a Transvaginal US useful for?
Checking endometrium / ovaries
When should you for a Transvaginal US in HMB? (2 things)
- Uterus / pelvic mass palpable @ exam
- Pharmacological tx failed
When should you do a Cervical smear in HMB?
If hasn’t had routine ones done
What investigation should you for HMB if sus infection?
High vaginal / endocervical swabs
What biopsy can be done for HMB?
Pipelle endometrial biopsy
When should you do a Pipelle endometrial biopsy in HMB? (3 things)
- Persistent intermenstrual bleeding
- 45+ age
- Pharmacological tx failed
When should you do a Hysteroscopy / Endometrial biopsy for HMB?
US identifies pathology / is inconclusive
What is the aim of management of HMB?
Improve woman’s quality of life (rather than specific reduction in blood loss volume)
When considering HMB management options, what should you discuss with the patient?
Impact on fertility
What is the management approach for HMB when there is no sus pathology?
3 tiered approach
What is the 3 tiered approach for HMB?
- Levonorgestral-releasing intrauterine system (LNG-IUS)
- Tranexamic acid / Mefanamic acid / COCP
- Progesterone only: Oral Norethisterone / Depo / Implant
What does Levonorgestral-releasing intrauterine system (LNG-IUS) also act as?
Contraceptive
How long is Levonorgestral-releasing intrauterine system (LNG-IUS) licenced for treatment?
5 years
How does Levonorgestral-releasing intrauterine system (LNG-IUS) work? (2 things)
- Thins endometrium
- Shrinks fibroids
What does the woman’s choice to use Tranexamic acid / Mefanamic acid / COCP depend on?
Her wishes for fertility
When should Tranexamic acid be used?
Only during menses to reduce bleeding
Does Tranexamic acid have an effect on fertility?
No
What is a pro for using Mefanamic acid?
Is an NSAID = offers analgesia for dysmenorrhoea
When should Mefanamic acid be used?
Only during menses to reduce bleeding
Does Mefanamic acid have an effect on fertility?
No
Does Oral Norethisterone work as a contraceptive?
No
Do Depo / Implant progesterone work as a contraceptive?
Yes
What are the main Surgical management options for HMB? (2 things)
- Endometrial ablation
- Hysterectomy
What are some other Surgical management options only for HMB caused by fibroids? (2 things)
- Myomectomy
- Uterine artery embolization
What is Endometrial ablation?
Lining of uterus obliterated
Who is Endometrial ablation suitable for?
Women who no longer wish to conceive
By how much does Endometrial ablation reduce HMB?
Up to 80%
Where can Endometrial ablation be performed?
Outpatient using local anaesthetic
What is the only definitive treatment for HMB?
Hysterectomy
What does Hysterectomy offer? (2 things)
- Amenorrhoea
- End to fertility
What are the types of Hysterectomy performed? (2 things)
- Subtotal (partial)
- Total
What is Subtotal (partial) Hysterectomy?
Removal of uterus but NOT cervix
What is Total Hysterectomy?
Removal of uterus and cervix
What openings can Hysterectomy be performed via? (2 things)
- Abdominal incision
- Vagina
