Menorrhagia

Question 1

What is menorrhagia according to NICE?

Answer 1

Excessive blood loss interferes with the physical, social, emotional and/or material quality of life

Question 2

What are causes of menorrhagia?

Answer 2

Polyp
Adenomyosis
Leiomyoma
Malignancy or hyperplasia

Coagulopathy
Ovulatory disorder
Endometrial (poorly understood)
Iatrogenic
Non-specified

Question 3

What is a polyp?

Answer 3

overgrowth of endometrial glands and stroma

Question 4

What is adenomyosis?

Answer 4

presence of non-neoplastic endometrial glands and stroma in myometrium

hypertrophy and hyperplasia of the myometrium

Question 5

How is adenomyosis diagnosed?

Answer 5

UUS or MRI

Question 6

What are risk factors for adenomyosis?

Answer 6

High parity
CS birth

(smoking helps)

Question 7

What is leiomyoma?

Answer 7

smooth muscle tumour of uterus

Question 8

What are risk factors for malignancy?

Answer 8

Obesity
PCOS (unopposed oestrogen)
Nullparity
Tamoxifen
FH breast/colon/endometrial cancer
DM
HTN

Question 9

What is the most common coagulopathy causing menorrhagia?

Answer 9

von Willebrand

Question 10

How does ovulatory causes lead to menorrhagia? Give examples

Answer 10

Unopposed oestrogen, infrequent cycles, overgrowth of endometrium leading to bleeding e.g. PCOS, hyperprolactinaemia, hypothyroidism

Question 11

What are iatrogenic causes of menorrhagia?

Answer 11

Mirena
COCP
HRT
Anti-coagulants e.g. warfarin

Question 12

What are non-classified causes of menorrhagia?

Answer 12

AV malformations
CS niche

Question 13

What are fibroids?

Answer 13

Uterine leiomyoma - benign tumours of the smooth muscle of the womb

Question 14

How are fibroids classified?

Answer 14

Subserosal – on outside of uterus
Intramural – within muscle of uterus
Submucosal – impinging on cavity of the uterus
Pedunculated – on a stem, usually referring to outside of uterus
Intracavitary – on stem within cavity of uterus

Question 15

What are endometrial polyps?

Answer 15

Hyperplastic localised overgrowth of endometrial glands and stroma - can affect fertility

Question 16

What are investigations for menorrhagia? Why?

Answer 16

Hysteroscopy - suspected submucosal fibroids, polyps, endometrial pathology
Pelvic ultrasound - suspected largery fibroids or adenomyosis

Question 17

What are treatments for menorrhagia?

Answer 17

Tranexamic acid
LNG-IUS
Endometrial ablation
Hysterectomy

Question 18

What is tranexamic acid in treatment of menorrhagia?

Answer 18

NSAID
500mg -1g tds PO while bleeding – up to 5 days
Can cause stomach irritation
Can be used long-term

Question 19

What is LNG-IUS in treatment of menorrhagia?

Answer 19

Mirena, Kyleena, Jaydess
Lifespan – 3-5 years
May have irregular bleeding for the first few months (up to 6 months)

(Not all LNG-IUS licensed for treatment of menorrhagia)

Question 20

What is endometrial ablation in treatment of menorrhagia?

Answer 20

Radiofrequency thermal ablation of endometrium

Significantly affects fertility but need to use contraception as well

Question 21

What is hysterectomy in treatment of menorrhagia?

Answer 21

Surgery of last resort - removal of uterus

Question 22

What are risks associated with hysterectomy?

Answer 22

Risk of intraoperative haemorrhage
Risk of damage to other organs – bowel, bladder, ureters
Risk of loss of ovarian function after surgery
Risk of impact on sexual feelings