Heavy Menstrual Bleeding

Question 1

Description

Answer 1

Menorrhagia - excess volume/duration (1wk+)

Question 2

Epidemiology

Answer 2

Prevalence increases with age, peaking between 30-50 but common in menstruating women

Question 3

Aetiology

Answer 3

Endocrine

• anovulation => excess endometrial growth
• PCOS => too many androgens
• HPO axis problem => hypothyroidism, hyperprolactinemia

Structural

• fibroids
• endometriosis
• uterine/cervical cancers

Pregnancy
-miscarriage, ectopic pregnancy (esp with pain)

Infectious
-PID

Iatrogenic
-HRT with exogenous estrogen

Question 4

Pathophysiology

Answer 4

FSH, O, LH, P are responsible for the cyclic regeneration of the endometrial layer.
-when this balance is disrupted => menorrhagia

Question 5

Symptoms

Answer 5

Age

Cycle regularity and length
How many pads/tampons needed

Parity and pregnancy?

Sexually active? Dyspareunia? => PID?

Fatigue, SOB on exertion, orthostatic symptoms? => anemia

Cold intolerance, weight gain, thin hair, skin => hypothyroidism

Easy bruising => coagulation disorder, may be familial

Unexplained weight loss => malignancy/chronic illness?

Question 6

Signs

Answer 6

Pallor in anemia
Goitre => hypothyroidism?

Abdo exam

• abdominal masses => ovarian tumours, fibroids?
• obesity, hair loss, edema, brittle nails => hypothyroidism
• obesity, hirsutism, striae, proximal muscle wasting => Cushings (amenorrhea,
• obesity, backne, facial and chest hair, menstrual irregularities
• acanthosis nigricans => insulin resistance and anovulation?

Question 7

Differential diagnoses

Answer 7

Iatrogenic/idiopathic

• fibroids => palpable pelvic mass
• endometriosis => back/rectal pain, dyspareunia, dysmenorrhea

Trauma

• miscarriage => previous missed period, sexually active, pelvic tenderness and pain
• ectopic pregnancy => previous missed period, past ectopic, pelvic tenderness
• recent IUD insertion => excess bleeding during/between periods

Infective/inflammatory
-PID => sexually active, dyspareunia, abnormal discharge, fever, pain

Neoplastic

• cervical => abnormal smear
• endometrial => bleeding post menopause

Endocrine

• PCOS => irregular cycle, hirsutism, backne, weight gain, insulin resistance
• hypothyroidism => weight gain, thin hair, low mood, constipation, cold, tired

Question 8

Investigations

Answer 8

Even if they are not sexually active, do a pregnancy test => rule out ectopics or miscarriage

FBC => anemia
TFT => hypothyroidism
Serum testosterone => androgen excess in PCOS, Cushings

Dexmeth suppression, urinary free cortisol => judge levels of ACTH and CS

HSG, TVUS => structural problems (fibroids, endometriosis)

Endometrial biopsy => rule out endometriosis especially post menopause

Question 9

Management

Answer 9

PCOS => weight loss, clomiphene

Endometriosis => combined oral pill to suppress HPO axis to reduce growth of ectopics

Ectopic => surgical/medical (methotrexate)

Cushings => surgical management of pituitary/adrenals

Hypothyroidism => levothyroxine