Menorrhagia

Question 1

What is heavy menstrual bleeding?

Answer 1

Heavy menstrual bleeding (HMB) is a description of excessive menstrual loss which interferes with a woman’s quality of life – either on its own or in combination with other symptoms. The definition of ‘excessive’ is set by the woman who presents with the problem.

It is said to affect 3% of women, with those aged 40–51 years most likely to present to healthcare services. HMB refers to bleeding that is not related to pregnancy, and only occurs during the woman’s reproductive years (i.e. not post-menopausal bleeding).

The majority of HMB cases (40-60%) cannot be attributed to any uterine, endocrine, haematological or infective pathology after investigation. These cases were formally referred to as ‘Dysfunctional Uterine Bleeding’ as a diagnosis of exclusion – however the term abnormal uterine bleeding (AUB) is now used.

Question 2

What are the causes of heavy menstrual bleeding?

Answer 2

PALM-COEIN

PALM - Structural Causes
P = polyps
A = adenomyosis
L = leiomas/fibroid
M = malignancy/ hyperplasia

COEIN = non structural causes
C = coagulopathy
O = ovarian dysfunction
E = endometrial
I = iatrogenic
N = not yet classified

Question 3

Risk factors of HMB?

Answer 3

age - menarche and coming up to menopause
obesity

Question 4

Clinical features of HMB?

Answer 4

1. bleeding during menstruation thought to be excessive by the woman
2. fatigue
3. SOB (caused by anaemia)

A menstrual cycle history should be taken. Inquire about smear history, contraception, medical history and medications – including those taken in an attempt to reduce menstrual bleeding.

Examination of the patient should include a general observation, abdominal palpation, speculum and bimanual examination. Assess for:

Vitals, BMI (risk factor for fibroids)
Signs of anemia
Signs of underlying coagulopathy (bruising, petechiae)
Abdominal exam –enlarged liver, pelvic masses, pelvic nodes
Pelvic exam: Speculum – smear if indicated; Bimanual – uterus fixed in endometriosis, feel for masses

Question 5

Differential diagnosis of Menorrhagia?

Answer 5

1. Pregnancy test - rule out ectopic/miscarriage
2. Endometrial/ cervical polyp - IMB/PC w/o dysm
3. Adenomyosis - dysm w/ bulky uterus on palp
4. Fibroids - w/ press sympts + bulky uterus
5. Malignancy -
6. Coagulopathy - vonwillebrand’s
7. Ovarian dysfunction - PCOS, hypothyroidism
8. Iatrogenic causes - e.g. copper coil
9. Endometriosis

Question 6

Investigations in HMB:

Answer 6

Bloods:
Full blood count
Anaemia tends to present after menstrual blood loss of 120ml.
Thyroid function test
If other signs and symptoms of underactive thyroid.
Other hormone testing
Not routine but considered if other clinical features e.g. suspicion of Polycystic ovary syndrome.
Coagulation screen + test for Von Willebrand’s
If suspicion of clotting disorder on history taking.

Imaging, hist & Microbiology:
Ultrasound pelvis
Transvaginal US is most clinically useful for assessing the endometrium and ovaries.
It should be considered if the uterus or a pelvic mass is palpable on examination, or if pharmacological treatment has failed.
Cervical smear
No need to repeat if up to date.
High vaginal and endocervical swabs for infection.
Pipelle endometrial biopsy:
Indications for biopsy include persistent intermenstrual bleeding, >45 years old, and/or failure of pharmacological treatment.
Hysteroscopy and endometrial biopsy:
Typically performed when ultrasound identifies pathology, or is inconclusive.

Question 7

Indications for pipelle endometrial biopsy?

Answer 7

persistent IMB, >45, failure of pharmacological intervention

Question 8

What is pharmacological management of HMB?

Answer 8

1. Mirena Coil* Levonorgestral-releasing intrauterine system (LNG-IUS):
   - Also acts as a contraceptive.
   - Is licensed for 5 years treatment.
   - Thins endometrium and can shrink fibroids.

2.Tranexamic acid, mefanamic acid or combined oral contraceptive pill:
- The choice is dependant on woman’s wishes for fertility.
- Tranexamic acid taken only during menses to reduce bleeding, no effect on fertility.
- Mefanamic acid is an NSAID so also offers analgesia for dysmenorrhoea, taken only during menses, no effect on fertility.

3. Progesterone only: oral norethisterone (Taken day 5-26 of cycle), depo or implant:
   - Oral norethisterone does not work as a contraceptive when taken in this manner, therefore other contraceptive methods should be applied.
   - Depo and implant progesterone are long active reversible contraceptives.

Question 9

What is the surgical management in HMB?

Answer 9

There are two main surgical treatment options for heavy menstrual bleeding; (i) Endometrial ablation and (ii) Hysterectomy.

Note: There are two additional surgical treatments – myomectomy and uterine artery embolisation. However, they are only used to treat HMB that is caused by fibroids.

Endometrial ablation is where the endometrial lining of the uterus is obliterated. It is suitable for women who no longer wish to conceive (although they will need to continue using contraception), and can reduce HMB by up to 80%. Ablation can be performed in the outpatient setting with local anaesthetic.

The only definitive treatment for HMB is hysterectomy. It offers amenorrhoea and an end to fertility. There are two main types performed:

Subtotal (partial) – removal of uterus, but not cervix.
Total – removal of cervix with uterus.
In both cases, the ovaries are not removed (unless abnormal). Hysterectomy can be performed through an abdominal incision or via the vagina.