Management of Menorrhagia

Management of Menorrhagia (Heavy Menstrual Bleeding) Dr Tan Yiap Loong Obstetric and Gynaecology Department Sarawak General Hospital

Definition Heavy menstrual bleeding (menorrhagia) is diagnosed when menstrual blood loss is considered excessive by the woman, interferes with women’s physical, social emotional, and/or quality of life Highly subjective and personal issue

Definition In research studies- between 60 ml and 80 ml per menstruation not practical in the clinical setting Accompanied by other symptoms, such as menstrual pain (dysmenorrhoea)

How common is it? Between 4% and 51.6%

Normal Menstrual Cycle Cycle length average 29 days Range 23 - 39 days Duration of flow Average 4 days 3 to 7 days Amount Average 35 mls Quality Non-clotting blood, endometrial debris

Previously…………. In the early 1990s it was estimated that at least 60% of women presenting with HMB would have a hysterectomy to treat the problem, often as a ﬁrst line. Emotive procedure womb and fertility often seen as being part of a woman ’ s identity undesirable for some people

Now…………. Things have changed and the number of hysterectomies is decreasing rapidly. In the UK, aim to be managed by primary health care Nevertheless, clinically, hysterectomy is associated with a very high satisfaction rate by those who have undergone the operation

Risk Factors While HMB may occur in the presence of histological abnormality, the association does not necessarily imply causality Uterine ﬁbroids (30%) epidemiological study in the UK found that site, size and number of ﬁbroids are linked to the level of MBL (Sulaiman S, Khaund A, McMillan N, et al. 2004)

Risk Factors Age ? an increase in MBL with age Polyps No studies linked the presence of uterine polyps with HMB. Blood disorders von Willebrand disease (vWD) 13.0-15.4% in women with menorrhagia compared with the general population (Woo YL, White B, Corbally R, et al. 2002)

Risk Factors Thyroid disorders Endometriosis/ Adenomyosis usually dysmenorrhoea but two studies have found that HMB may be a signiﬁcant secondary symptom Racial groups Lifestyle observational studies showed impact on MBL

Risk Factors Uterine Pathology? Results of 20 observational and diagnostic studies show that the majority of women with HMB have no histological abnormality that can be implicated in causing HMB Rare for a woman who has presented with HMB and has undergone investigations to have an underlying pre-malignant or malignant condition RCOG women aged between 35 and 54 years, eight of every 10,000 women who presented with HMB in primary care would have endometrial carcinoma.

Risk Factors Dysfunctional uterine bleeding No organic cause Frequently due to anovulation Others PID Malignancy IUCD Medications (Tamoxifen, Unapposed oestrogen treatment)

What is our goal? Heavy menstrual bleeding (HMB) should be recognised as having a major impact on a woman ’ s quality of life, and any intervention should aim to improve this rather than focusing on menstrual blood loss. [C] (NICE 2007)

How should I assess a woman with menorrhagia?

History and Physical Examination Nature of the bleeding (flooding, clots, double padding,etc) and related symptoms (anaemia) Directed to identify potential pathology Explore women’s prespective, ideas, concerns Previous treatments

History and Physical Examination Physical examination if an abnormality is suspected (e.g. if there is intermenstrual or postcoital bleeding, or pelvic pain or pressure) Recommended before all ; LNG-IUS ﬁttings investigations for structural abnormalities investigations for histological abnormalities

History and Physical Examination Measurement of MBL Direct- alkaline haematin Accurate and precise Impractical Little impact on management Indirect- Pictorial Blood Loss Assessment Chart (PBAC) Highly variable NOT RECOMMENDED ROUTINELY SHOULD BE DETERMINED BY PATIENT HERSELF

Investigations (Laboratory) FBC test - in all women with HMB Coagulation profile -if HMB since menarche/ family history Serum Ferritin - not routinely Hormone testing - not recommended Thyroid function test - when signs and symptoms present

Investigations (Structural and Histological) Ultrasound sensitivity 48 - 100% specificity 12 - 100% better at identifying fibroids than hysteroscopy less accurate for identifying polyps or endometrial disease should be undertaken in the following circumstances: uterus is palpable abdominally vaginal examination reveals a pelvic mass of uncertain origin pharmaceutical treatment fails Hysteroscopy when ultrasound results are inconclusive to determine the exact location of a fibroid or the exact nature of the abnormality

Investigations (Structural and Histological) Magnetic resonance imaging (MRI) Dilatation and curettage alone should not be used as a diagnostic tool Endometrial biopsy persistent intermenstrual bleeding in women aged 45 and over treatment failure or ineffective treatment

What advice and counselling should I give to a woman with menorrhagia?

Discuss……. Natural variability and range of menstrual blood loss and reassure the woman (if appropriate) Different treatment options acceptability effectiveness of treatments adverse effects contraception implications of treatment on fertility

Give…….. The opportunity to review and agree any treatment decision. Adequate time and support from healthcare professionals in the decision-making process

When should I prescribe pharmaceutical treatment in women presenting with menorrhagia?

Drug Treatment Pharmaceutical treatment (recommended first-line) no symptoms or signs suggestive of underlying pathology (structural or histological uterine abnormalities are awaiting the results of investigations

Drug Treatment If either hormonal or non-hormonal treatments are acceptable (descending order) levonorgestrel-releasing intrauterine system (Mirena®) provided long-term (at least 12-months) use is anticipated tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens ( Depo-Provera®) .

Drug Treatment Levonorgestrel-releasing intrauterine system (Mirena®) RCTs reduction between 71% and 96% Full beneﬁt of treatment may not be seen for 6 months 30% amenorrhoea RCT (ECLIPSE) LNG-IUS vs other pharmaceutical treatments

Drug Treatment Tranexamic acid 1 g (2 X 500 mg tablets) three to four times daily, from the onset of bleeding for up to 4 days reductions in MBL (29% to 58%) NSAIDs (mefenamic acid or naproxen) reductions in MBL (20% to 49%) dysmenorrhoea

Drug Treatment COCs reduction of MBL of 43% Oral progestogen used long-term reduces MBL by 83% Etonogestrel implant (Implanon ® ) no licence for the treatment of HMB Depot medroxyprogesterone acetate (DMPA) No evidence Amenorrhea is a side effect (NICE)

Drug Treatment If hormonal treatments are not acceptable to the woman, then either tranexamic acid or NSAIDs can be used GnRH analogue prior to surgery other treatment options for uterine ﬁbroids, including surgery or uterine artery embolisation (UAE), are contraindicated ‘ add-back ’ therapy amenorrhea rates of 89%

What should I do if initial drug treatment is ineffective in a woman with menorrhagia? A second pharmaceutical treatment Add on another drug rather than immediate referral to surgery. Use of NSAIDs and/or tranexamic acid should be stopped if it does not improve symptoms within three menstrual cycles

How can I rapidly stop heavy bleeding, if necessary? Oral norethisterone, 5 mg three times daily (licensed use) or, in very severe cases, 10 mg three times daily (unlicensed use), then tapering down to 5 mg three times daily for a further week

Not Recommended Oral progestogens in the luteal phase only Danazol (side effects) Etamsylate

When should I refer? Malignancy is suspected refer urgently (within 2 weeks) Significant negative impact on her quality of life despite adequate trials of pharmaceutical treatment Anaemia - not improved despite treatment (other causes excluded) make a routine referral. Wants to consider surgical options

Surgical Treatment Used as the initial treatment for HMB? Unclear Endometrial ablation may be offered Hysterectomy should not be used as a ﬁrst-line treatment solely for HMB Whether a pharmaceutical intervention should always be tried ﬁrst?

Surgical Treatment Non-hysterectomy or interventional radiology Hysterectomy

Non-hysterectomy or interventional radiology Endometrial ablation 1st generation (TCRE, Rollerball) 2nd generation (MEA, Inpedence-controlled bipolar radiofrequency, balloon thermal) Affects fertility Use of effective contraception following procedure 50% amenorrhoea, 95% satisfaction rate

Non-hysterectomy or interventional radiology Uterine artery embolisation (UAE) Fertility is potentially retained

Non-hysterectomy or interventional radiology Hysteroscopic myomectomy Myomectomy

Hysterectomy Fibroids >3cm + severe impact on QoL Desire for amenorrhoea Other treatments failed, contraindicated, declined No desire to retain uterus or fertility Fully informed women request it

Hysterectomy Route First line : Vaginal Second line : Abdominal Ovaries may also be removed 100% amenorrhoea 95% satisfaction rate

Referrences Sulaiman S, Khaund A, McMillan N, et al. Uterine ﬁbroids - do size and location determine menstrual blood loss? European Journal of Obstetrics and Gynecology 2004;115(1):85 - 9 Woo YL, White B, Corbally R, et al. Von Willebrand ’ s disease: an important cause of dysfunctional uterine bleeding. Blood Coagulation and Fibrinolysis 2002;13(2):89 - 93

Management of Menorrhagia

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Management of Menorrhagia