Heavy Menstrual Bleeding Flashcards
On average, how much blood is lost during menstruation?
40ml
What constitutes excessive menstrual blood loss?
> 80ml
In practice:
1. Changing pads every 1-2 hours
- Bleeding lasting more than seven days
- Passing large clots
List causes of menorrhagia.
- Dysfunctional uterine bleeding (no identifiable cause)
- Extremes of reproductive age
- Fibroids
- Endometriosis and adenomyosis
- Pelvic inflammatory disease (infection)
- Contraceptives, particularly the copper coil
- Anticoagulant medications
- Bleeding disorders (e.g. Von Willebrand disease)
- Endocrine disorders (diabetes and hypothyroidism)
- Connective tissue disorders
- Endometrial hyperplasia or cancer
- Polycystic ovarian syndrome
What are important things to ask about when taking a gynaecological history?
- Age at menarche
- Cycle length, days menstruating and variation
- Intermenstrual bleeding and post coital bleeding
- Contraceptive history
- Sexual history
- Possibility of pregnancy
- Plans for future pregnancies
- Cervical screening history
- Migraines with or without aura (for the pill)
- Past medical history and past drug history
- Smoking and alcohol history
- Family history
Pelvic examination with a speculum and bimanual is usually performed to investigate heavy menstrual bleeding, however in which circumstances may it not be performed?
If there is a straightfoward history heavy menstrual bleeding without other risk factors or symptoms
Or
They are young and not sexually active
What is pelvic examination mainly assessing for?
- Fibroids
- Ascites
- Cancers
Why is a FBC done in all women with heavy periods?
Iron deficiency anaemia
Name 3 instances where outpatient hysteroscopy should be arranged (when investigating menorrhagia).
- Suspected submucosal fibroids
- Suspected endometrial pathology (e.g. endometrial hyperplasia or cancer)
- Persistent intermenstrual bleeding
Name 3 instances where pelvic and transvaginal ultrasound should be arranged (when investigating menorrhagia).
- Possible large fibroids (palpale pelvic mass)
- Possible adenomyosis (associated pelvic pain or tenderness on examination)
- Examination is difficult to interpret (e.g. obesity)
- Hysteroscopy is declined
When might a swab be needed?
Evidence of infection (e.g. abnormal discharge or suggestive sexual history)
When might a coagulation screen be needed?
If there is a family history of clotting disorders (e.g. Von Willebrand disease) or periods have been heavy since menarche
When might a ferritin be needed?
If clinically anaemic
What is a method of managing menorrhagia for women who do not want contraception and have no associated pain?
Transexamic acid (antifibrinolytic which reduces bleeding)
What is a method of managing menorrhagia for women who do not want contraception and have associated pain?
Mefanamic acid (NSAID - reduces bleeding and pain)
What is the management of menorrhagia if contraception is wanted/ acceptable?
- Mirena coil (first line)
- Combined oral contraceptive pill
- Cyclical oral progestogens e.g. norethisterone 5mg three times daily from day 5-26
- Progesterone-only contraception
