Heavy Menstural Bleeding

Question 1

Definition

Answer 1

• Bleeding that has an adverse impact on QoL
• >7 days or <3 week cycle
• >80mls but don’t measure

Question 2

Causes of HMB

Answer 2

• Commonest
  
  • Dysfunctional uterine bleeding (i.e. no structural cause)
• Common
  
  • Structural causes
    
    • Fibroids
    • Endometriosis
    • IUCD
• Rare
  
  • Disorders of cuagulation
    
    • von Willebrand’s disease

Question 3

DUB

Answer 3

• Ovulatory
  
  • Excessive prostanoids in utero - effect on enrometrial bleeding
• Anovulatory
  
  • Excessive endometrial thickness - post-menarche, pre-manopause

Question 4

Presentation

Answer 4

• Heavily within normal cycle
• For more and 7 days
• More frequently than every 3 weeks
• Effect on QoL
• Anaemia and related symptoms

NB - Common in teenagers and menopausal women

Question 5

Diagnosis of HMB

Answer 5

• History
  
  • Basic (age parity, sexual partners, occupation, plans for family)
  • Bleeding pattern (K=x/y, intensity, dysmenorrhoea, periodic bleeding)
  • QoL issues
  • Management by GP (of cycle and anaemia)
• Examination
  
  • General, abdominal and vaginal
• Investigation
  
  • FBC
  • Transvaginal US (usually only if abnormal VE)
  • Cervical smear (only if due)
  • Endometrial biopsy if >45 years

Question 6

Management of HMB

Answer 6

• Expectant
• Medical
  
  • COCP
  • TXA
  • Mefenamic acid
  • Progestogens (norehisterone, Mirena IUS)
• Surgical
  
  • Endometrial ablation
  • Polypectomy
  • Myomectomy
  • Hysterectomy

Question 7

Hysterectomy

Answer 7

• Adbominal - standard for abdominal pathology
• Vaginal - for prolapse
• Laparoscopic - shorted stay
• Total - for HMB, fibroids, cancer
• Sub-total - if cervic not easy to remove or patient’s choice