Women's Health : Menorrhagia

Question 1

What is the NICE definition of menorrhagia?

Answer 1

Excessive menstrual blood loss that interferes with a woman’s physical, social, emotional, or material quality of life.

Question 2

List the primary and secondary differentials for heavy menstrual bleeding (HMB).

Answer 2

Primary (50% of cases): No identified cause. Secondary causes:
Fibroids
Endometrial polyps
Gynaecological cancer
Endometriosis/adenomyosis
Systemic causes: hypothyroidism, inherited coagulopathy (e.g., von Willebrand’s disease).

Question 3

What initial investigation should be conducted for suspected heavy menstrual bleeding?

Answer 3

Full blood count to check for anaemia.

Question 4

When should further investigations be considered for HMB?

Answer 4

When guided by the patient’s history to identify potential underlying causes.

Question 5

What is the first-line management for heavy menstrual bleeding?

Answer 5

Levonorgestrel-releasing intrauterine system (LNG-IUS).

Question 6

What are the second-line options for managing HMB?

Answer 6

tranexamic acid (anti-fibrinolytic) or alternative hormonal treatment e.g. COCP, POP.

Question 7

Define uterine fibroids.

Answer 7

Benign uterine tumors composed of smooth muscle and connective tissue, also known as leiomyomata.

Question 8

What is the proposed origin of uterine fibroids?

Answer 8

(Probably) derived from myometrial stem cells; considered to be oestrogen-dependent tumours, they express higher than normal numbers of certain oestrogen and progesterone receptors.

Question 9

Why are fibroids considered oestrogen-dependent?

Answer 9

They express higher than normal numbers of certain oestrogen and progesterone receptors.

Question 10

What are the proposed mechanisms by which fibroids contribute to HMB?

Answer 10

• proposed mechanisms include distortion of uterine lining and abnormal humoral factors due to altered histology of the overlying endometrium.

Question 11

What are the four types of uterine fibroids based on their location?

Answer 11

○ Intramural - contained within the myometrium. ○ Submucosal - projecting inwardly. ○ Subserosal - projecting outwardly. ○ Pedunculated - attached on a stem.

Question 12

List the risk factors for uterine fibroids

Answer 12

High BMI, age in 40s, black ethnicity, low serum vitamin D levels

Question 13

How does high BMI contribute to the development of fibroids?

Answer 13

Increased adiposity leads to increased peripheral aromatase levels - therefore increasing circulating oestrogen due to conversion of adrenal DHEA into oestradiol. - The increased oestrogen has an inhibitory effect on the HPG axis, leading to anovulation, decreased progesterone levels and thus reduced progestogenic endometrial protection (menses). - Fibroids are oestrogen dependent; high oestrogen and low progesterone stimulates their growth.

Question 14

What are the typical symptoms and signs of uterine fibroids?

Answer 14

Symptoms: Menorrhagia, pelvic pain/pressure, bloating, dysmenorrhea. Signs: Palpable mass or enlarged uterus on bimanual examination.

Question 15

What is the first-line investigation for suspected uterine fibroids?

Answer 15

Transabdominal and transvaginal ultrasound scan.

Question 16

First Line Management fibroids managed as per HMB guidelines?

Answer 16

: offer treatment as per HMB (LNG-IUS, tranexamic acid, alternative hormonal contraception)

Question 17

Second Line Management of fibroids

Answer 17

GnRH agonist e.g. leuprorelin or antiprogesterone e.g. mifepristone

Question 18

What surgical options are available for managing uterine fibroids?

Answer 18

○ Myomectomy (surgical removal of fibroids) - fertility-preserving ○ Uterine artery embolisation. ○ Hysterectomy

Question 19

What is uterine artery embolisation, and how is it performed?

Answer 19

(deliberate infarction of fibroid tissue whilst preserving surrounding uterus; performed by interventional radiologist, via percutaneous femoral access)