Menorrhagia

Question 1

What is it?

Answer 1

Excess menstrual bleeding that interferes with daily life

Question 2

Why might a patient present?

At what age does it tend to be worse?

What else may the patient present with?

What may an enlarged uterus indicate?

Answer 2

Change in volume (clots/floods)
Worsening impact

Extremes of reproductive life

Anaemia

Fibroids

Question 3

Causes:

DUB - what is it?

Ovulatory dysfunction - when does it tend to happen?

Uterine disease

Sexual-health related?

Inflammatory disease - 1

Type of contraception - 1

Thyroid disease - 1

What type of coagulopathy may cause menorrhagia?

Answer 3

Dysfunctional uterine bleeding in absence of pathology

Extremes of reproductive life - irregular and/or infrequent period 
---
Fibroids 
Adenomyosis 
Endometrial cancer 
Hyperplasia 
Polyps 
----
PID

IUCD

Hypothyroidism

Von Willebrand Disease, being on warfarin

Question 4

Investigations:

What examinations need to be done?

Bedside - what can be done?

Bloods and why? - 3

Imaging and why?

Answer 4

Abdominal and vaginal examination

Cervical smear and STI screen

FBC - anaemia
TFT - hypothyroidism
Clotting studies - coagulopathy

TVUS - pelvic pathology suspected
Hysteroscopy - endometrial cancer - biopsy

Question 5

Management - Hormonal:

1st line - standard Rx**:

• Type
• Name
• MOA

2nd line:
- Type of contraception

3rd line:
- Norethisterone - what is it? when is it used? what caution should be taken and why?

4th line - rarely used:
- GnRH analogues - what do they do and what type of patient are they used in?

Answer 5

Intra-uterine system (IUS)

Mirena

COC
—-
Progestogen - used to stop short term bleeding
Shouldn’t be used in women trying to conceive as it stops ovulation
—-
Induces a temporary menopausal state

Treating VERY anaemic patients

Question 6

Management - Non-hormonal:

NSAIDs:

• Why are they used?
• Examples

Anti-fibrinolytic:

• MOA
• Name

When are these both taken?

When can non-hormonal Rx be useful?

Answer 6

Inhibit prostaglandins, therefore, less bleeding and help dysmenorrhoea

Reduce losses - prevents the breakdown of clots

Tranexamic acid

Taken during days of bleeding

In someone trying to conceive

Question 7

Management - Surgical:

When is surgery needed?

First-line?

Second-line?

What if a women has fibroids and wishes to retain fertility? - 2

What if a woman has fibroids and does not wishes to retain fertility? - 1

Answer 7

If they don’t respond to medical Rx

Endometrial ablation - contraception is still needed

Hysterectomy

Myomectomy
Uterine artery embolisation

Hysterectomy