Menorrhagia

Question 1

What are the objective and subjective definitions of menorrhagia?

Answer 1

Objective definition: The total blood loss of > 80 ml per menses.

Subjective definition: Excessive blood loss that interferes with a woman’s physical, social, emotional and/or quality of life.

Question 2

What are the most common causes of menorrhagia?

Answer 2

1. Dysfunctional Uterine Bleeding (DUB) (50% of cases) (no local or systemic cause found)
2. Anovulatory cycles: These are more common at the extremes of age.
3. Local -
   
   • Uterine fibroids (30%)
   • Uterine Polyps (10%)
   • Ovarian Tumours
   • Cervical & Endometrial cancer
   • PID
   • Intrauterine devices.
4. Systemic - Thyroid Disorders, Bleeding disorders (e.g. Von Willebrand Disease)

Question 3

What is the investigation pathway for menorrhagia?

Answer 3

1. Examination
2. Blood Tests
   
   • Exclude anaemia - FBC (NEEDED)
   • Exclude systemic cause - TFT and Coag. (Optional)
3. Consider USS if uterus is palpable or there is a pelvic mass - TV USS
4. Consider referral

Question 4

When do HOT TOPICS 2016 suggest a woman with HMB be referred?

Answer 4

• New onset inter-menstrual bleeding >40 yrs.
• Persistent inter-Menstrual bleeding in women of any age.
• Aged > 45 yrs and treatment failure or ineffective treatment.

Question 5

When should someone with menorrhagia be referred to a specialist from primary care?

(According to NICE)

Answer 5

• Alarm Symptoms (2WW)

Routine:

1. Symptoms affecting quality of life - Routine.
2. Woman wants surgery rather than to persist with medical treatment. - Routine.
3. Iron deficiency anaemia - Clinical judgemet.

Question 6

What are the ALARM symptoms for menorrhagia in primary care?

(NICE)

Answer 6

1. Persistent IMB or PCB.
2. Unexplained vulval lump or vulval bleeding due to ulceration.
3. A palpable abdominal mass that is not obviously uterine fibroids.

Question 7

What is the medical treatment pathway for menorrhagia?

Answer 7

1. First line
   
   • IUS (Can decrease menstrual flow by >90%)
     
     • Supported by The ECLIPSE Trial
     • Nearly 1/3 want it removed in 1 year.
2. Second line
   
   • Tranexamic acid (Can decrease blood loss by 50%) & few S/E.
     
     • Available OTC as Cyklo-F or Femstrual
   • NSAIDs - good for dysmenorrhoea (naproxen, ibuprofen or mefanamic acid) - stop taking when pregnant.
   • COCP - be aware of contraindications.
3. Third Line
   
   • Norethisterone 5 mg TDS from day 5 to 26 of cycle or injected long-acting progestogens.
4. Fourth Line
   
   • GnRH analogues - (Only to be used in secondary care) - Menopausal S/E.
   • Selective Progesterone Receptor Modulators - Ullipristal 5mg OD.
     
     • Noninferior to GnRH agonists and causes much less menopausal side effects.

Question 8

What are the surgical options for menorrhagia?

Answer 8

• Uterine myomectomy can preserve fertility.
• In women with HMB alone and a uterus no bigger than a 10 week pregnancy, endometrial ablation should be considered before hysterectomy
• Hysterectomy has a higher satisfaction rate than endometrial destruction or the IUS, so worth discussing if the IUS fails

Question 9

How do you rapidly stop heavy bleeding?

Answer 9

• Oral norethisterone, 5 mg three times daily for 10 days, usually stops bleeding within one to three days. Inform the woman that a withdrawal bleed will occur two to four days after stopping treatment.
• If bleeding is exceptionally heavy (‘flooding’), 10 mg three times daily (off-label dose) may provide better results (get informed consent). This should then be tapered down to 5 mg three times daily for about a week once bleeding has stopped.