Menorrhagia

Question 1

Define menorrhagia

Answer 1

Heavy menstrual bleeding (HMB) in an otherwise normal menstrual cycle
Clinical: Excessive blood loss that affects woman’s physical, emotional, social or material QoL
Objective: >80mL in otherwise normal cycle [max amount you can lose without becoming iron deficient on a normal diet]

Question 2

Outline the aetiology of menorrhagia

Answer 2

Uterine fibroids (30%)
Polyps (10%) [cervical, endometrial]
Carcinoma [cervical, endometrial]
Ovarian tumour
PID
Coagulopathy [system pathology[

Question 3

What investigations would you perform for menorrhagia?

Answer 3

Hb - assess effect of loss
Coagulation & thyroid function - systemic
Transvaginal ultrasound - endometrial thickness, uterine fibroid, ovarian mass, polyps

Question 4

When should you perform an endometrial biopsy?

Hysteroscopy with Pipelle

Answer 4

Endometrial thickness >10mm
Polyp suspected
Women >40 with recent onset menorrhagia OR also has IMB
Not responding to treatment

Question 5

Outline the first line pharmaceutical treatment of HMB?

Outline mechanism of action & side effects.

Answer 5

Levonorgestrel-releasing intrauterine system (LNG-IUS)
- Slow release progestogen
- Prevents prolif. of endometrium
Contraceptive.
Side effects;
- Irreg. bleeding ~6months
- Amenorrhoea
- Rare: uterine perforation when inserted

Question 6

Outline the second line pharmaceutical treatment of HMB?

Outline mechanism of action & side effects.

Answer 6

1) Tranexamic acid (non-hormonal)
- Oral antifibrinolytic tablets - inhibit plagminogen to plasmin conversion
S/E - indigestion & diarrhoea
2) NSAIDs
- Oral tablets that reduce production of prostaglandin
- Mefanamic acid
S/E - indigestion & diarrhoea
3) Combined oral contraceptives
- Prevent prolif. of endometrium
S/E - Mood change, headache & nausea, myalgia, fluid retention

Question 7

Outline the third line pharmaceutical treatment of HMB?

Outline mechanism of action & side effects.

Answer 7

1) Oral progestogen (norethisterone)
- Prevent proliferation of endometrium
S/E - weight gain, bloating, myalgia, acne
2) Injected progestogen
- Prevent prolif. of endometrium
S/E - weight gain, bloating, myalgia, acne

Question 8

Outline the fourth line pharmaceutical treatment of HMB?

Outline mechanism of action & side effects.

Answer 8

GnRH analogue injection
- Stops production of oestrogen & progesterone
S/E - Menopausal like symptoms (hot flushes, sweats, vaginal dryness) - Rare: osteoporosis

Question 9

What are the possible surgical & radiological treatments treatments for a women with HMB which;

• No desire to conceive
• Has a normal uterus
• +/- small fibroids (<3cm)

Answer 9

Endometrial ablation - destroys womb lining
1st generation;
- Transcervical resection of endometrium (TCRE)
- Rollerball
2nd generation;
- Free fluid or balloon thermal
- Microwave
- Impedance-controlled bipolar radiofrequency

Question 10

What are the possible surgical & radiological treatments treatments for a women with HMB which;

• Fibroids >3cm
• Wants to retain uterus

Answer 10

Uterine artery embolisation - small particles injected into uterine arteries
Hysteroscopic/ normal myomectomy - surgical removal of fibroids

Question 11

What are the possible surgical & radiological treatments treatments for a women with HMB which;

• Fibroids >3cm
• No desire to conceive

Answer 11

Hysterectomy - vaginal (1st line), abdominal (2nd line)
+/- oophorectomy

Do not remove healthy ovaries.