Heavy Menstrual Bleeding Flashcards
HMB is the most common gynaecological presentation. True or false?
True
1/10 of all gynae referrals
What is another term for heavy menstrual bleeding?
Menorrhagia
What is the most common cause?
Dysfunctional uterine bleeding (DUB) - heavy menstrual bleeding with no recognisable pelvic pathology
= a diagnosis of exclusion
60% of menorrhagia is due to…
Dysfunctional uterine bleeding
What pathological causes are there?
Fibroids Adenomyosis Endometriosis Polyps Pelvic infection e.g PID IUCD
Why can the IUD make periods heavier?
Copper toxicity causes inflammation of the endometrium, which cause increase bleeding
What medical causes are there?
Hypothyroidism
Liver disease
What abnormal clotting disorders can cause menorrhagia?
Von Willibrand disease Thrombocytopenia Platelet disorders Leukaemia Coagulation disorders
What type of cancer can cause menorrhagia?
Endometrial carcinoma
Also hyperplasia can cause menorrhagia
What percentage of those with subjective menorrhagia have greater than normal loss?
50%
What percentage of women with MBL greater than 80ml/ cycle consider their periods heavy?
60%
It is difficult to measure blood loss, so what questions can you ask to help quantify blood loss?
Impact on quality of life and presence of anaemia
Ask about number of pads/ tampons used in a day and how soaked they are
Do they need to take a change of clothing when they go out?
Is sleep disrupted by bleeding?
Do they bleed through clothes?
Clots or flooding?
Do they plan day around proximity to toilet?
What symptoms and signs are associated?
Heavy, prolonged vaginal bleeding
Often worse at extremes of reproductive life
Dysmenorrhea
Symptoms of anaemia
IMB and PCB are abnormal - need investigation
What could an enlarged uterus suggest?
Fibroids
Adenomyosis
What investigations should be done?
Exclude pregnancy FBC and haematinics if indicated TFTs if clinically hypothyroid Cervical smear if due STI screen If over 45 with risk factors or failed medical therapy: Transvaginal ultrasound Hysteroscopy +/- biopsy
When would a women be considered low risk?
Less than 45
No IMB and regular cycle
No risk factors for endometrial cancer
What test should be carried out for all women with HMB?
FBC
When should testing for coagulation disorders be done?
Have had HMB since period started
Personal or family history suggesting a coagulation disorder
When should a women be considered high risk?
Over 45
IMB
Suspected pathology
RFs for endometrial cancer
What are risk factors for endometrial cancer?
Obesity Early menarche and late menopause Nulliparity PCOS Unapposed oestrogen Tamoxifen Previous breast or ovarian cancer BRCA 1/2 Endometrial polyps or hyperplasia DM, HTN, Parkinson’s FH HNPCC
What medical treatment options are there?
Symptom control:
Tranexamic acid 1g TDS for up to 4 days
Mefenamic acid 500mg / 8hrs
(Combination of both works well, if women can have NSAIDS)
Hormone control:
Mirena IUS - should be considered first line
POP
COCP
How does mirena IUS work?
Releases levonorgestrel into endometrial cavity leading to atrophy
By how much does the IUS reduce bleeding?
By up to 86% at 3 months and 97% by one year
30% are amenorrhoeic by a year
What side effects are associated with the IUS?
Irregular bleeding for first 4-6 months
Progestogenic effects
