Menorrhagia

Question 1

Menorrhagia - Specific questions

Answer 1

• Number of sanitary towels used per day
• Bleeding through clothes or onto bedsheets at night (‘flooding’)
• Affect on everyday life
• Symptoms of iron deficiency anaemia
  
  • Lethargy
  • Breathlessness
  • Dizziness

Question 2

Differentials for menorrhagia

• Structural/Local
• Endocrine
• Iatrogenic

Answer 2

Dysfunctional uterine bleeding (40-60%)

• No recognisable pathology

Anovulatory cycles / PCOS (20%)

• ↑ endometrial growth and hyperplasia due to unopposed oestrogen secretion
• Associated with the extremes of reproductive life
  
  • PCOS
    
    • Hirsutism
    • Acne
    • Weight gain

Local causes

• Fibroids
  
  • Pelvic pain/pressure
  • Bowel/bladder pressure symptoms
  • FHx of fibroids
• Polyps (spotting)
• Adenomyosis
  
  • Parous, age 40-50
  • Bladder/bowel pressure symptoms
• Endometriosis
  
  • Age 20-40
  • Cramping pelvic/abdominal pain before menses
  • Back/rectal pain
  • Dyspareunia
• PID
  
  • Lower abdominal pain
  • Fever
  • Discharge
  • Hx of STD
• Endometrial cancer
  
  • Lethargy
  • Weight loss
  • FHx

Systemic

• Hypothyroidism
  
  • Lethargy
  • Weight gain
  • Constipation
  • Cold intolerance
  • Dry skin/hair

Intra-uterine contraceptive device (IUCD)

Previous sterilisation

Bleeding

• Liver/renal failure
• Anticoagulants
• Clotting disorders (e.g. von-Willebrand’s disease).

Question 3

Menorrhagia history

Answer 3

• PC
  
  • Menstrual Hx
    
    • Is your cycle regular?
    • How many days does your period last?
    • How many days in between each period?
    • When was your LMP?
    • How many tampons/pads?
    • Do you ever bleed through clothing/onto bedsheets?
    • Have you ever noticed any clots?
    • How does this impact on your everyday life?
    • Any bleeding in between cycles?
    • Are you sexually active? Do you ever bleed after intercourse?
  • Cervical smear history
    
    • Up to date?
    • When was last one?
    • Any abnormal results?
• Contraception
  
  • Do you use any form of contraception?
  • PLANS FOR FERTILITY?
    
    • This may affect management
• Other symptoms
  
  • Pain
    
    • Dyspareunia
    • Dysmenorrhoea
  • Discharge
  • Urinary symptoms
  • Bowels
  • PCOS (hirsutism)
  • Symptoms of anaemia
• PMH
  
  • Diabetes
  • Thyroid
  • Menopausal symptoms
    
    • Drug history?
    • Smoking
    • Alcohol
    • Allergies
• FHx
  
  • von Willebrand’s
    
    • Do you bruise easily?
    • Bleed when brushing teeth?
• Social history

Question 4

Investigations for menorrhagia

Answer 4

• Transvaginal ultrasound (structural)
  
  • Fibroids
  • Endometrial thickness (normally < 12mm pre-menopausal)
• Hysteroscopy + biopsy
• FBC
• TFTs
• Testosterone (PCOS)

Question 5

Management of menorrhagia

Answer 5

*Governed by fertility intentions!*

• 1st line
  
  • Mirena coil
• Drugs
  
  • Tranexamic acid (antifibrinolytic)
  • Mefanamic acid (NSAID)
  • COCP
• Surgery
  
  • Infertility
    
    • Endometrial ablation
    • Hysterectomy
  • Fertility preserved
    
    • Uterine artery embolisation
    • Hysteroscopic myomectomy