Menorrhagia

Question 1

What is it

Answer 1

Menorrhagia refers to excessive, abnormal uterine bleeding, which occurs over several consecutive cycles and interferes with a woman’s physical, emotional, social, and material quality of life.

Question 2

What is the normal frequency of period bleeding

Answer 2

every 21-35 days

Question 3

How regular should a normal female be

Answer 3

Consistent cycle frequency

Question 4

What volume is normal for menses

Answer 4

5-80mL

Question 5

What is the average bleeding duration

Answer 5

5 days

Question 6

What are the markers of Menorrhagia

Answer 6

Blood loss 80ml<
increased frequency of blood soaked pads/tampons or blood loss that interferes with daily activities

Question 7

What are the causes of Menorrhagia

Answer 7

ovaries and uterus, systemic disorders and iatrogenic causes.

Question 8

What are the ovarian and uterine pathology causes (PUPEE)

Answer 8

Uterine fibroids (leiomyomas)
Endometriosis & adenomyosis
Pelvic inflammatory disease
Endometrial polyps & hyperplasia
Polycystic ovarian syndrome

Question 9

What is the term when no cause is identified for menorrhagia

Answer 9

In 40-60% of cases no cause is identified. This is termed dysfunctional uterine bleeding (DUB).

Question 10

What are the systemic disorders that can cause it

Answer 10

Coagulation disorders
Hypothyroidism
Liver/renal disease

Question 11

What are the iatrogenic causes

Answer 11

Anticoagulants
Contraceptives (e.g. IUD)

Question 12

A useful mnemonic for remembering the important causes of menorrhagia is ‘PERIODS’ - what are they

Answer 12

P: Polyps & Pelvic inflammatory disease
E: Endometriosis & Endometrial carcinoma
R: Really bad hypothyroidism
I: Intrauterine contraceptive device
O: polycystic Ovary syndrome
D: Dysfunctional uterine bleeding
S: Submucosal fibroids

Question 13

What are uterine fibroids

Answer 13

Uterine fibroids (leiomyomas) are benign tumours that arise from the muscle layer of the uterus termed the myometrium.

Question 14

What are fibroids maintained by

Answer 14

High levels of oestrogen and progesterone

Question 15

Who is at risk of fibroids

Answer 15

Their incidence progressively increases towards menopause and they are more common in black females.

Question 16

What are fibroids classified by

Answer 16

based on location (i.e. subserosal, intramural, submucosal).

Question 17

What are the clinical features of fibroids

Answer 17

menorrhagia, abdominal swelling, pelvic pain, dyspareunia, dysmenorrhoea and urinary/bowel symptoms. The diagnosis of fibroids is based on pelvic ultrasonography and treatment usually revolves around management of menorrhagia.

Question 18

What are Iuds made from

Answer 18

made of copper and may be inserted for up to 10 years in duration.

Question 19

How do IUDS work

Answer 19

They are effective contraceptives that work by causing cervical mucus to be thicker in consistency and alters motility within the uterotubal system. Collectively this prevents sperm migration.

Question 20

What other intrauterine systems may be used and can be treatment for menorrhagia

Answer 20

newer intrauterine contraceptive systems (e.g. mirena), which may be used as a treatment for menorrhagia.

Question 21

What are the clinical features of menorrhagia besides heavy blood loss

Answer 21

Post-coital bleeding
Dyspareunia
Dysmenorrhoea
Intermenstrual bleeding
Pelvic pain and/or pressure symptoms
Vaginal discharge
Hirsutism
Bruises (coagulation disorders)

Question 22

How is diagnosis achieved

Answer 22

Diagnosis of menorrhagia relies on an agreement between patient and clinician that menstrual bleeding experienced is heavy.

Question 23

When are further investigations warranted

Answer 23

Further investigations may be warranted depending on the presenting symptoms and examination findings of the patient (e.g. a pelvic mass warrants urgent investigation with imaging). Up to 40-60% of cases of menorrhagia have no underlying cause known as dysfunctional uterine bleeding.

Question 24

What investigations may bemused to delineate the underlying cause and complications

Answer 24

Basic investigations can be arranged in primary care including pregnancy test, full blood count and pelvic ultrasound scan. Other tests are dependent on the suspected underlying cause and screening results.

Question 25

When is a pregnancy test conducted

Answer 25

A pregnancy test should be completed in all pre-menopausal patients with abnormal uterine bleeding. The test is simple and non-invasive.

Question 26

What the FBC show

Answer 26

iron-deficiency anaemia due to the excess loss of blood and subsequent iron stores.

Question 27

What would the pelvic ultrasound show

Answer 27

Pelvic ultrasound is the modality of choice to assess for structural causes of menorrhagia (e.g. fibroids).

Question 28

What are the indications for pelvic ultrasound

Answer 28

The main indications for pelvic ultrasound include palpable uterus abdominally, a pelvic mass (consider two week wait referral), and menorrhagia not responsive to conventional treatment.