Menstruation and Menstrual Disorders - Menorrhagia

Question 1

What is Menorrhagia?

Answer 1

Heavy menstrual bleeding. Diagnosis is based on symptoms (e.g. changing pads, more days, clots); not on volume.

Question 2

Normal Blood Loss vs. Excessive Blood Loss.

Answer 2

Normal = 40ml.
Excessive = +80ml.

Question 3

Aetiology of Menorrhagia (12).

Answer 3

1. Dysfunctional Uterine Bleeding (No Identifiable Cause).
2. Extremes of Reproductive Age (Anovulatory Cycles).
3. Fibroids.
4. Endometriosis and Adenomyosis.
5. Pelvic Inflammatory Disease (Infection).
6. Contraceptives (IUD).
7. Anticoagulant Medications.
8. Bleeding Disorders (e.g. von-Willebrand).
9. Endocrine Disorders (e.g. Diabetes, Hypothyroidism).
10. Connective Tissue Disorders.
11. Endometrial Hyperplasia/Cancer (Postmenopausal).
12. PCOS.

Question 4

What is Dysfunctional Uterine Bleeding?

Answer 4

Menorrhagia in the absence of underlying pathology, approximately 50% of cases.

Question 5

Investigations in Menorrhagia.

Answer 5

1. Pelvic Examination (with Speculum and Bimanual) - check for fibroids, ascites, cancer.
2. FBC = Iron-Deficiency Anaemia.

Question 6

Indications of Outpatient Hysteroscopy in Menorrhagia (3).

Answer 6

1. Suspected Submucosal Fibroids.
2. Suspected Endometrial Pathology e.g. Hyperplasia, Cancer.
3. Persistent Menstrual Bleeding.

Question 7

Indications of Pelvic and Transvaginal Ultrasound in Menorrhagia (4).

Answer 7

1. Possible Large Fibroids (Palpable Pelvic Mass).
2. Possible Adenomyosis.
3. Inadequate Examination e.g. Obesity.
4. Refusal for Hysteroscopy.

Question 8

Management of Menorrhagia (2).

Answer 8

1. Manage underlying cause.
   2 : If Contraception is acceptable, 1st Line = Mirena; 2nd Line = COCP; 3rd Line = Cyclical Oral Progestogens.
   2B : If Contraception is unacceptable, provide symptomatic relief either with (i) 500mg TDS Mefenamic Acid if there is associated pain; (ii) or 1g TDS Tranexamic Acid if there is no associated pain. Start both drugs on the first day of the period. If no improvement, try the other drug whilst awaiting secondary care referral.

Question 9

Mechanism of Action of Tranexamic Acid.

Answer 9

Antifibrinolytic and a synthetic derivative of Lysine that reversibly binds to Lysine receptors sites on Plasminogen or plasmin, to prevent Plasmin from binding to and degrading Fibrin.

Question 10

Indications of Tranexamic Acid (2).

Answer 10

1. Help treat Fibrinogen (reduces bleeding).

2. IV Bolus followed by an Infusion in cases of Major Haemorrhage.

Question 11

Last Line Options for Management of Menorrhagia (2).

Answer 11

1. Endometrial (Thermal Balloon) Ablation.

2. Hysterectomy.

Question 12

Mechanism of Action of Mefenamic Acid.

Answer 12

NSAID.