Heavy Menstrual Bleeding Flashcards
What is a normal blood loss during menstruation?
What is abnormal?
- normal blood loss during menstruation is around 40ml
- menorrhagia involves > 80ml loss
although actual blood loss is rarely measured
How is heavy menstrual bleeding quantified?
- changing pads every 1-2 hours
- bleeding lasting > 7 days
- passing large clots
a diagnosis is made based on a self report of “very heavy periods”
What are the gynaecological causes of menorrhagia?
- endometriosis / adenomyosis
- PCOS
- endometrial hyperplasia / cancer
- pelvic inflammatory disease
- contraceptives (particularly copper coil)
- fibroids
What are the other causes of menorrhagia?
- dysfunctional uterine bleeding
- extremes of reproductive age
- anticoagulants
- bleeding disorders
- endocrine disorders
- connective tissue disorders
dysfunctional uterine bleeding = no identificable cause
What endocrine disorders are associated with menorrhagia?
diabetes + hypothyroidism
What questions need to be asked in any presentation with a gynaecological problem?
- age at menarche
- cycle length / variation
- IMB / PCB
- contraceptive history
- sexual history
- possibility of pregnancy + plans for future pregnancy
- cervical screening history
- migraines (with or without aura)
migraines are important when considering the COCP
What is the first-line investigation for menorrhagia?
bimanual examination + speculum
- this assesses for fibroids, ascites + cancer
- not necessary in a straightforward history without other RFs / symptoms
OR
- if they are young and not sexually active
What other investigation should be performed in all women with menorrhagia?
full blood count
- this assesses for iron deficiency anaemia
When should outpatient hysteroscopy be arranged?
- suspected submucosal fibroids
- suspected endometrial pathology (i.e. hyperplasia / cancer)
- persistent intermenstrual bleeding
When should a pelvic + transvaginal USS be arranged?
- possible large fibroids (palpable pelvic mass)
- possible adenomyosis (associated pelvic pain / tenderness on exam)
- hysteroscopy is declined
- examination is difficult to interpret (e.g. obesity)
What additional tests may be considered in someone with menorrhagia?
swabs:
- if evidence of infection (e.g. abnormal discharge / sexually active)
**coagulation screen:*
- if family history of clotting disorders
ferritin:
- if anaemic
TFTs:
- if other symptoms of hypothyroidism
What is the first step in the management of menorrhagia?
exclude underlying pathology
- e.g. anaemia, fibroids, bleeding disorders, cancer
- if causes are identified, treat these appropriately
What is the second step in the management of menorrhagia?
establish whether the use of contraception is required / acceptable
If a woman declines contraception, what are the treatment options?
tranexamic acid:
- this is an antifibrinolytic that reduces bleeding
- it is used when there is NO associated pain
mefenamic acid:
- this is an NSAID that reduces bleeding + pain
- used when there is associated pain
What are the options for treatment when contraception is appropriate?
- first line is Mirena coil
- then the COCP
- and then cyclical oral progestogens
- progesterone-only contraception may also be tried as it can suppress menstruation
DO NOT give COCP in history of migraines
