Heavy Menstrual Bleeding Flashcards
Average blood loss per menstrual cycle?
35mLs per cycle
Average length of menses?
3-7 d
What is menorrhagia?
Prolonged (7d+) or excessive (80mLs+ per cycle) occurring at regular intervals
What is metrorrhagia?
Irregular cycle and more frequent
What is menometrorrhagia?
Prolonged or excessive bleeding occurring at irregular and more frequent intervals
What is metros taxis?
Acute, very heavy bleed
Ddx of vaginal bleeding?
- DUB
- Systemic: endocrine, bleeding disorders, liver disease)
- Adenomyosis
- Fibroids
- Polyps
- Inection
- Carcinoma
- Iatrogenic
- Pregnancy
What is DUB?
No organic pathology; diagnosis of exclusion. May be ovulatory or anovulatory.
What is ovulatory DUB?
Aetiology unclear. May be due to excessive prostacyclin production which increases vasodilation and decreases platelet aggregation.
What is pathophysiology of anovulatory DUB?
Normal: with ovulation CL makes progesterone
Anovulatory:
- no ovulation, CL does not develop.
- No progesterone produced.
- Unopposed oestrogen = endometrial thickening until outgrows blood supply - necrosis and shedding. Cycles therefore long and irregular. d
What are the RFx for anovulatory DUB?
Extremes of reproductive life
- Adolescence
- Perimenopause
But can occur at any stage
What are the consequences of anovulatory DUB?
May present with any menstrual pattern.
- Fe deficiency anemia
- Infertility
- If chronic: inc RFx endometrial hyperplasia and cancer
Endocrine causes of anovulatory DUB?
- Thyroid
- Pituitary / adrenal disorders
- PCOS
- Significant weight changes
What are the uterine and local causes of DUB?
- Myometrium: fibroids, adenomyosis
- Endometrium: polyps, hyperplasia, carcima, endometritis, IUD
- Cervix: polyps, Ca
- Ovarian pathology
Proportion of women with fibroids?
20% of 30yo women
RFx for fibroids?
- Nulliparity
- Obesity
- +ve FHx
Symptoms of fibroids?
Mostly asymptomatic
- Pressure
- Frequency (urinary)
- Menstrual disturbance
- Pregnancy issues
- Pain: if necrosis, torsion
Mx fibroids?
- Hormonal if symptomatic
- Hysteroscopic resection if sub mucous
- Myomectomy
- Hysterectomy
- Embolisation / ablation
What is adenomyosis?
Endometrial glands within myometrium
CFx of adenomyosis?
- Multiparous; 30s/40s
- Menorrhagia
- Dysmenorrhoea
- Bulky, tender uterus
Ix of choice in adenomyosis diagnosis?
MRI
USS is insensitive
Mx adenomyosis?
- Induce amenorrhoea with hormonal treatment
- GnRH analogues
- Mirena
- Hysterectomy
Presentation of endometrial carcinoma?
- PMB
- Menorrhagia
- IMB
RFx endometrial carcinoma?
- Chronic anovulatory cycles
- Unopposed oestrogen therapy
- Obesity
- PCOS
- Nulliparous
- Endometrial hyperplasia
- FHx HNPCC
- Tamoxifen
How is endometrial cancer diagnosed?
Endometrial sampling
Iatrogenic causes of DUB?
- OCP
- Depot provera
- Implanon
- IUD
- Anticoagulation
- Chemotherapy (thrombocytopenia)
Bimanual exam features of adenomyosis?
Large, tender, globular uterus
What is first line endometrial sampling?
Pipette first line.
- OPD; no anaesthetic
- Normal does not exclude problem
What should be done in pipelle endometrial sampling shows malignancy?
If malignancy: refer straight to oncology - no Hysteroscopy D&C
Gold standard endometrial sampling to exclude carcinoma or hyperplsia?
Hysteroscopy D & C
Risks of Hysteroscopy D&C?
- Uterine perforation
- Infection
- Gas embolism
Work up for PMB?
- TV USS and pipelle
- If both normal (ET under 4mm) can observe
- If recurs, or any abnormality: HD&C
Medical Mx of HMB?
- Treat cause
- A. Non Hormonal: PG inhibitors, anti-fibrinolytics
- B. Hormonal: OCP, depot provera, GnRH analogues
- C. Procedural: Mirena
Surgical Mx of HMB indication?
If medical treatment fails and fertility not desired
Surgical Mx of HMB?
- Endometrial ablation
- Hysterectomy
Commonest cause of teenagers with HMB?
Anovulatory DUB (80% ovulatory 3y after menarche)
metrostaxis Mx?
- ABCs; resuscitate
- Tranexamic acid first line
- High dose progesterone acutely
Hx to elicit when evlaluating HMB?
- Age
- Parity
- LNMP and ?preg
- frequency / vol / pattern
- Impact on QoL
- Comorbidities (diabetes, obesity, PCOS, thyroid disease, bleeding disorders)
- Pelvic pain or pressure
- Fhx: endometriosis, endometrial or bowel cancer
