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A - MSRA Gynaecology > Menorrhagia > Flashcards

Menorrhagia Flashcards

1
Q

What is the techinical definition of menorrhagia?

A

> 80ml/month of loss

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2
Q

What % of women are affected by menorrhagia?

A

10%

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3
Q

What is the clinical definition of menorrhagia?

A

Excessive menstrual loss leading to interference with physical, emotional, social or material quality of a woman’s life

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4
Q

What type of conditions are most commonly causing menorrhagia?

A

Benign ones

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5
Q

What can menorrhagia often lead to?

A

Iron deficiency anaemia

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6
Q

What can iron-deficiency have an impact on?

A

Woman’s work, family and social life

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7
Q

What are the groups of causes of menorrhagia?

A
  • Structural
  • Non-structural
  • Iatrogenic
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8
Q

What are the possible structural causes of menorrhagia?

A
  • Leiomyomata
  • Endometrial carcinoma
  • Adenomyosis
  • Polyps
  • Endometrial hyperplasia
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9
Q

What is the more common term for leiomyomata?

A

Fibroids

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10
Q

What is the most common structural cause of menorrhagia?

A

Fibroids

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11
Q

When is endometrial cancer more rare?

A

Under 40 years

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12
Q

What is endometrial cancer more likely to cause before menorrhagia?

A

Irregular bleeding

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13
Q

What is adenomyosis usually associated with?

A

Uniformly enlarged, tender uterus, menorrhagia and dysmenorrhoea

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14
Q

What do polyps usually cause as well as menorrhagia?

A

IMB

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15
Q

What can endometrial hyperplasia be associated with?

A

Irregular anovulatory cycles and overlap with disturbed ovulation

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16
Q

What can endometrial hyperplasia be a precursor of?

A

Endometrial cancer

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17
Q

What are the non-structural causes of menorrhagia?

A
  • Disturbed ovulation or anovulation

- Disturbed mechanisms of endometrial haemostasis

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18
Q

How else can disturbed ovulation or anovulation affect the menstrual cycle?

A
  • Irregular
  • Infrequent
  • Prolonged
  • Potentially life-threatening bleeding
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19
Q

What often leads to disturbed ovulation causing menorrhagia?

A

Unopposed oestrogen leading to thickening and hyperplasia of the endometrium which then breaks down in a patchy and erratic fashion

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20
Q

When do most cases of ovulatory disorders occur?

A
  • Menopause transition
  • Adolescence
  • Due to endocrinopahties
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21
Q

What endocrinopahties can cause ovulatory disorders?

A
  • PCOS

- Hypothyroidism

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22
Q

What can cause disturbed mechanisms of endometrial haemostasis?

A
  • Excessive local production of fibrinolytic factors e.g. TPA
  • Deficiencies in local vasoconstrictors
  • Increased local vasodilators
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23
Q

What is a common iatrogenic cause of menorrhagia?

A

Copper IUD

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24
Q

Why should women with menorrhagia have a general examination?

A

For signs of anaemia or thyroid disease

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25
Q

What additional examinations may women with menorrhagia require?

A
  • Pelvic
  • Speculum
  • Smear
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26
Q

What is the first line test for menorrhagia?

A

Bloods

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27
Q

What bloods are useful when assessing menorrhagia?

A
  • FBC
  • Serum ferretin
  • Serum transferrin receptor
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28
Q

When can treatment be started after blood tests alone for menorrhagia?

A

If examination and history were not of a sinister nature

29
Q

When should patients with menorrhagia be referred for further investigation?

A
  • Risk factors for endometrial cancer
  • Persistent IMB
  • Abnormal cervical smear
  • Significant pelvic pain
  • Not responding to first-line treatment after 6 months
30
Q

What is the purpose of further investigations for menorrhagia?

A

To exclude pelvic pathology, particularly malignancy

31
Q

What are the main forms of additional investigation for menorrhagia?

A
  • Transvaginal USS
  • Endometrial biopsy
  • Hysteroscopy
  • Investigations for systemic causes
  • Thyroid screening
32
Q

What can transvaginal USS identify in menorrhagia?

A

Presence of structural lesions e.g. polyps

33
Q

What does hysteroscopy provide in menorrhagia?

A

View of uterine cavity

34
Q

How can hysteroscopy be performed?

A

Under local or general anaesthetic

35
Q

What is an important investigation for systemic causes of menorrhagia?

A

Coagulation screen for disorders of haemostasis

36
Q

Give an example of a clotting disorder that can cause menorrhagia?

A

Von Willebrand’s disease

37
Q

When is coagulation screening indicated in menorrhagia?

A
  • Young women

- History/family history of coagulopathies

38
Q

When is a thyroid screening indicted in menorrhagia?

A

Suggestive features in history or on examination

39
Q

What are the main types of treatment for menorrhagia?

A
  • Medical

- Surgical

40
Q

What does the medical management of menorrhagia in the absence of malignancy depend on?

A
  • If contraception is required
  • If irregularity is an issue
  • Presence of any contraindications
41
Q

How can the medical treatments of menorrhagia be divided?

A
  • Hormonal

- Non-horomonal

42
Q

What is the advantage of non-hormonal treatments for menorrhagia?

A

Only need to be taken when menstruating

43
Q

What are some non-hormonal medications used in menorrhagia?

A
  • NSAIDs

- Tranexamic acid

44
Q

What are some examples of NSAIDs used in menorrhagia?

A
  • Megenamic acid

- Ibuprofen

45
Q

What is the mechanism of action of NSAIDs?

A

Reduce prostaglandin synthesis

46
Q

By how much can NSAIDs reduce blood loss in menorrhagia?

A

30%

47
Q

What is a secondary advantage of NSAIDs for menorrhagia?

A

Analgesic properties

48
Q

What is the main side effect of NSAIDs?

A

Gastric irritation

49
Q

What sort of drug is tranexamic acid?

A

Antifibrinolytic

50
Q

By how much does tranexamic acid reduce blood loss in menorrhagia?

A

50%

51
Q

Who should tranexamic acid be avoided?

A

People with a history of thromboembolic disease

52
Q

What are the options for the hormonal management of menorrhagia?

A
  • COCP
  • Levonorgestrel IUS
  • Synthetic oral progesterones
53
Q

What % of monthly blood loss reduction can COCP give?

A

~30%

54
Q

What % of monthly blood loss reduction can levonorgestrel IUS give?

A

~90%

55
Q

In what regime are oral progesterones given to treat menorrhagia?

A

21/28 days

56
Q

When can oral progesterones be given in higher doses for menorrhagia?

A

In an acute situation to control excessive bleeding

57
Q

What is the problem with oral progesterones for menorrhagia?

A

Associated with more side-effects

58
Q

What is the recommended first line treatment for menorrhagia?

A

IUS

59
Q

What are the main surgical treatments for menorrhagia?

A
  • Endometrial resection
  • Endometrial ablation
  • Hysterectomy
60
Q

What is endometrial resection?

A

Removal of the endometrium with hysteroscope

61
Q

What is endometrial ablation?

A

Destruction of the endometrium using intrauterine heating/cooling devices

62
Q

What treatment can be given prior to endometrial ablation?

A

GnRH analogues to thin the endometrium

63
Q

What are the potential complications of endometrial ablation?

A
  • Intraoperative uterine perforation
  • Damage to other organs
  • Fluid overload
  • Need for further surgery
64
Q

What new techniques for endometrial ablation are emerging?

A

Balloon ablation

65
Q

What is the advantage of balloon ablation?

A

Allow for precise destruction of the endometrium reducing side effects

66
Q

What % of patients who have ablation will be amenorrhoeic post-op?

A

30-70%

67
Q

What % of patients will have significant reduction in menstrual bleeding after ablation?

A

20-30%

68
Q

What is the definitive surgical treatment for menorrhagia?

A

Hysterectomy

69
Q

Who is hysterectomy most appropriate for in menorrhagia?

A

Those with pelvic pathology e.g. fibroids

A - MSRA Gynaecology (52 decks)

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