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Menorrhagia
Menorrhagia, or heavy menstrual bleeding, is defined as menstrual blood loss greater than 80ml over several cycles. It is a common cause of iron deficiency anemia in women. Potential causes include physiological changes, dysfunctional uterine bleeding, fibroids, polyps, infections, blood disorders, and iatrogenic factors. Evaluation involves a history, examination, blood tests, ultrasound, and possibly endometrial biopsy. Treatment depends on underlying cause but may include NSAIDs, antifibrinolytics, contraceptive pills, progestogen therapies, endometrial ablation or resection, and hysterectomy.
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Menorrhagia involves heavy menstrual bleeding (over 80ml). It's common in women aged 30-49 and can lead to iron deficiency.
A comprehensive history and examination are essential for diagnosing menorrhagia, including menstrual charts and pelvic exams.
Referral guidelines include heavier bleeding, persistent intermenstrual bleeding, or adverse response to treatment.
Menorrhagia can be ovulatory or anovulatory, with altered prostaglandin levels affecting menstrual loss.
Causes include physiological, hormonal, infectious, neoplastic, and other factors; 50% due to physiological and DUB.
Investigations include blood tests, swabs, ultrasound, and biopsies, especially for women over 40 or with new symptoms.
Treatments involve addressing the underlying pathology and may include NSAIDs, hormonal therapies, and surgical options like hysterectomy.
The presentation concludes with acknowledgments.
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Menorrhagia
- 1. Dr J RomainMenorrhagia
- 2. Definition Heavy, regularbleeding over several cycles with menstrual blood loss greater than 80mls
- 3. In the UKâŠEach year causes 1 in 20 women between 30-49yrs to visit their GP Commonest cause of iron deficiency anaemia in women of reproductive age
- 4. Interesting Facts Tenfoldincrease in number of periods women experience (reducing family size, less lactation, early menarche, late menopause) If loss >60mls, neg iron balance can occur Clinicians rely on womanâs assessment of menstrual blood loss, which may be inaccurate in 50% cases
- 5. History Full gynaecologicalhistory Notoriously inaccurate amount of blood loss Number of pads/tampons used Clots/ flooding Frequency of accidents Menstrual chart can be useful
- 6. Examination Weight Anysigns of endocrine disturbance Abdominal and pelvic examination Cervical smear if indicated
- 7. NICE Referral GuidelinesIf there is suspicion of underlying cancer They also have persistant intermenstrual or postcoital bleeding Despite 3 months of drug treatment the bleeding is still heavy and interfering with quality of life Wish to explore the possibility of surgical intervention rather than persist with drugs They have severe anaemia failing to respond to drugs
- 8. Pathophysiology Menstrual bleedingeither ovulatory or anovulatory Regular and painful- ovulatory Irregular and painless- anovulatory With menorrhagia there is evidence of elevated levels of prostaglandins in endometrium and altered responsiveness to vasodilator PGE2.
- 9. Pathophysiology Ovulatory bleedingis associated with normal levels of circulating progesterone and oestradiol, therefore altered prostaglandin synthesis is thought to be responsible for increased menstrual loss Ratio of PGE2 and prostacyclin (causing vasodilatation and inhibition of platelet aggregation) and PGF2a (promoting vasoconstriction and platelet aggregation) is significant
- 10. Aetiology Physiological- normalloss but interpreted as excessive. Commonly occuring in those who stop the OCP Dysfunctional Uterine Bleeding- diagnosis made after pelvic pathology excluded Congenital- increased endometrial surface area, eg bicornuate uterus Traumatic, eg. IUD
- 11. Aetiology Infective, eg.Chronic PID Neoplastic, eg. Fibroids, endometrial polyps Metabolic, eg. Hyperthyroid Psychological factors Adenomyosis Blood dyscrasias Iatrogenic, eg. Warfarin NOTE- physiological and DUB account for 50%
- 12. Investigations Full bloodcount Thyroid function tests, clotting profiles If suspect infection- endocervical swabs Vaginal Ultrasonography- measure thickness of endometrium (<5mm normal). Detects abnormalities of the cavity eg.polyps. Can assess ovaries and uterus
- 13. Investigations Endometrial biopsyshould be performed if- menorrhagia is a recent phenomenon woman over 40 yrs if there is any intermenstrual bleeding Even if procedure is performed via D&C it is diagnostic and NOT therapeutic
- 14. Treatment If anypathology is found it must be treated, rest aim to treat dysfunctional uterine bleeding Anovulatory- extremes of age. OCP can help. Cyclical progestogens used to induce regular withdrawl bleeds. If these stop, woman has reached menopause Acute arrest for heavy bleeding- high dose reducing course of progestogen
- 15. Treatment NSAIDS- inhibitsynthesis of prostaglandins, decrease blood loss by up to 30%. Mefanamic acid, given for a few days during menstruation Antifibrinolytic drugs- reduce enhanced fibrinolytic activity within the uterus. Up to 50% reduction. Tranexamic acid Oral Contraceptive Pill- ovulation suppressed and oestrogen levels remain constant.
- 16. Treatment Hormone releasingIUDâs- progestogen released causes atrophy of endometrium. Can cause amenorrhoea Danazol- anti gonadotrophin. Induces atrophy of endometrium due to low level of circulating sex steroids. Androgenic side effects not tolerated well- virilizing effects
- 17. Treatment Endometrial ablationor resection- visualised hysteroscopically and ablated. Many methods-laser, rollerball, hydrothermal, cryoablation, microwave. Can become amenorrhoeic but not always successful Hysterectomy- definative treatment if family complete.
- 18.