Menorrhagia Flashcards
What is the techinical definition of menorrhagia?
> 80ml/month of loss
What % of women are affected by menorrhagia?
10%
What is the clinical definition of menorrhagia?
Excessive menstrual loss leading to interference with physical, emotional, social or material quality of a woman’s life
What type of conditions are most commonly causing menorrhagia?
Benign ones
What can menorrhagia often lead to?
Iron deficiency anaemia
What can iron-deficiency have an impact on?
Woman’s work, family and social life
What are the groups of causes of menorrhagia?
- Structural
- Non-structural
- Iatrogenic
What are the possible structural causes of menorrhagia?
- Leiomyomata
- Endometrial carcinoma
- Adenomyosis
- Polyps
- Endometrial hyperplasia
What is the more common term for leiomyomata?
Fibroids
What is the most common structural cause of menorrhagia?
Fibroids
When is endometrial cancer more rare?
Under 40 years
What is endometrial cancer more likely to cause before menorrhagia?
Irregular bleeding
What is adenomyosis usually associated with?
Uniformly enlarged, tender uterus, menorrhagia and dysmenorrhoea
What do polyps usually cause as well as menorrhagia?
IMB
What can endometrial hyperplasia be associated with?
Irregular anovulatory cycles and overlap with disturbed ovulation
What can endometrial hyperplasia be a precursor of?
Endometrial cancer
What are the non-structural causes of menorrhagia?
- Disturbed ovulation or anovulation
- Disturbed mechanisms of endometrial haemostasis
How else can disturbed ovulation or anovulation affect the menstrual cycle?
- Irregular
- Infrequent
- Prolonged
- Potentially life-threatening bleeding
What often leads to disturbed ovulation causing menorrhagia?
Unopposed oestrogen leading to thickening and hyperplasia of the endometrium which then breaks down in a patchy and erratic fashion
When do most cases of ovulatory disorders occur?
- Menopause transition
- Adolescence
- Due to endocrinopahties
What endocrinopahties can cause ovulatory disorders?
- PCOS
- Hypothyroidism
What can cause disturbed mechanisms of endometrial haemostasis?
- Excessive local production of fibrinolytic factors e.g. TPA
- Deficiencies in local vasoconstrictors
- Increased local vasodilators
What is a common iatrogenic cause of menorrhagia?
Copper IUD
Why should women with menorrhagia have a general examination?
For signs of anaemia or thyroid disease
What additional examinations may women with menorrhagia require?
- Pelvic
- Speculum
- Smear
What is the first line test for menorrhagia?
Bloods
What bloods are useful when assessing menorrhagia?
- FBC
- Serum ferretin
- Serum transferrin receptor
When can treatment be started after blood tests alone for menorrhagia?
If examination and history were not of a sinister nature
When should patients with menorrhagia be referred for further investigation?
- Risk factors for endometrial cancer
- Persistent IMB
- Abnormal cervical smear
- Significant pelvic pain
- Not responding to first-line treatment after 6 months
What is the purpose of further investigations for menorrhagia?
To exclude pelvic pathology, particularly malignancy
What are the main forms of additional investigation for menorrhagia?
- Transvaginal USS
- Endometrial biopsy
- Hysteroscopy
- Investigations for systemic causes
- Thyroid screening
What can transvaginal USS identify in menorrhagia?
Presence of structural lesions e.g. polyps
What does hysteroscopy provide in menorrhagia?
View of uterine cavity
How can hysteroscopy be performed?
Under local or general anaesthetic
What is an important investigation for systemic causes of menorrhagia?
Coagulation screen for disorders of haemostasis
Give an example of a clotting disorder that can cause menorrhagia?
Von Willebrand’s disease
When is coagulation screening indicated in menorrhagia?
- Young women
- History/family history of coagulopathies
When is a thyroid screening indicted in menorrhagia?
Suggestive features in history or on examination
What are the main types of treatment for menorrhagia?
- Medical
- Surgical
What does the medical management of menorrhagia in the absence of malignancy depend on?
- If contraception is required
- If irregularity is an issue
- Presence of any contraindications
How can the medical treatments of menorrhagia be divided?
- Hormonal
- Non-horomonal
What is the advantage of non-hormonal treatments for menorrhagia?
Only need to be taken when menstruating
What are some non-hormonal medications used in menorrhagia?
- NSAIDs
- Tranexamic acid
What are some examples of NSAIDs used in menorrhagia?
- Megenamic acid
- Ibuprofen
What is the mechanism of action of NSAIDs?
Reduce prostaglandin synthesis
By how much can NSAIDs reduce blood loss in menorrhagia?
30%
What is a secondary advantage of NSAIDs for menorrhagia?
Analgesic properties
What is the main side effect of NSAIDs?
Gastric irritation
What sort of drug is tranexamic acid?
Antifibrinolytic
By how much does tranexamic acid reduce blood loss in menorrhagia?
50%
Who should tranexamic acid be avoided?
People with a history of thromboembolic disease
What are the options for the hormonal management of menorrhagia?
- COCP
- Levonorgestrel IUS
- Synthetic oral progesterones
What % of monthly blood loss reduction can COCP give?
~30%
What % of monthly blood loss reduction can levonorgestrel IUS give?
~90%
In what regime are oral progesterones given to treat menorrhagia?
21/28 days
When can oral progesterones be given in higher doses for menorrhagia?
In an acute situation to control excessive bleeding
What is the problem with oral progesterones for menorrhagia?
Associated with more side-effects
What is the recommended first line treatment for menorrhagia?
IUS
What are the main surgical treatments for menorrhagia?
- Endometrial resection
- Endometrial ablation
- Hysterectomy
What is endometrial resection?
Removal of the endometrium with hysteroscope
What is endometrial ablation?
Destruction of the endometrium using intrauterine heating/cooling devices
What treatment can be given prior to endometrial ablation?
GnRH analogues to thin the endometrium
What are the potential complications of endometrial ablation?
- Intraoperative uterine perforation
- Damage to other organs
- Fluid overload
- Need for further surgery
What new techniques for endometrial ablation are emerging?
Balloon ablation
What is the advantage of balloon ablation?
Allow for precise destruction of the endometrium reducing side effects
What % of patients who have ablation will be amenorrhoeic post-op?
30-70%
What % of patients will have significant reduction in menstrual bleeding after ablation?
20-30%
What is the definitive surgical treatment for menorrhagia?
Hysterectomy
Who is hysterectomy most appropriate for in menorrhagia?
Those with pelvic pathology e.g. fibroids
