Heavy Menstrual Bleeding

Question 1

Describe the causes of heavy menstrual bleeding

Answer 1

DUB = endometrial (secretory endometrium) or ovulatory (anovulation –> unopposed oes, no progesterone –> long, irregular cycles)

Local Causes =

• Polyps: IMB
• Adenomyosis
• Leiomyoma (fibroids)
• Malignancy - Cervical Ca or Endometrial (present with IMB, PCB, PMB)
• Ovulatory - PCOS
• Endometrial hyperplasia or Ca

Systemic - hypo/hyper-thyroid, DM
Pregnancy-rel - miscarriage, ectopic
Iatrogenic - contraception (Implanon, IUD, depot-provera), anticoag (Warfarin, Heparin), chemo (thrombocytopaenia)
Coag - haemophilia, coag disorder

Question 2

Discuss the approach to evaluation of heavy menstrual bleeding, including the principles of gynaecological history

Answer 2

History

• HOPC: Q (how many tampons/pads, flooding, colour, clots), S (how often, interfere life), T (regular/irregular, duration cycle:bleed, similar ep past, progression), Context (new med), A/R, Assoc (syx of anaemia, Ca)
• RF’s HMB
• Other bleeding/discharge: IMB, PCB, rectal/urine, discharge
• Pain: sex, urination, defecation, pelvic
• Pregnancy + contraception: prev pregnancies/how many children/breast feeding, contraception, sex active, pregnant now?, family planning
• Pap smears: up to date? abnormal results, prev infect
• Past medical: Gyn problems, coagulation disorders, Ca, thyroid
• Medications/Allergies
• Smoke/alco
• Past surgical: prev surgeries - esp pelvic
• Past FHx: similar bleeding problems, Ca (ovarian, endometrial, bowel, breast)
• Social Hx

Question 3

Outline the medical and surgical management options for heavy menstrual bleeding under differing clinical circumstances

Answer 3

Medical: Non-Hormonal (transexamic acid, anti-PG); Hormonal (cont COCP, Progesterone, Depot-provera, GnRH analogue)

Procedural: Implanon, Mirena

Surgical: endometrial ablation, MRGFUS (focused US/artery embolisation - fibroids), Hysterectomy (+oophorectomy)

Question 4

Discuss the approach to evaluation of heavy menstrual bleeding, including the principles of gynaecological examination

Answer 4

1. Vitals: BP, postural drop, tachycardia
2. General: sx anaemia, weight, endocrine disturbance (hirtuism, acne; goitre, tremor, exomthalmos)
3. Abdo: palpation masses (e.g. fibroids in uterus)
4. Speculum: fibroids, polyps, discharge/bleeding, pap smear
5. Bimanual: size/shape uterus (large irregular = fibroids, large tender = adenomyosis), axis (fixed = endometriosis, PID), tenderness on cervical movement (= PID), adnexal mass